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Walter E. Fernald 
State School 

Waverley, Massachusetts 

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All rights reserved 

Copyright, 1902, 

Set up and electrotyped May, 1902. 

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J. 8. Cuihing & Co. — Berwick tt Smith 
Norwood Mass. U.S.A. 


The motive for this work was to make the teachings 
of Kraepelin in psychiatry accessible to American medical 
students and general practitioners, and, at the same time, 
to provide a full, but concise, text-book, not only for the 
author's own classes in psychiatry in the Medical Depart- 
ment of Yale University, but as well for other Ameri- 
can teachers who follow Kraepelin' s views. Urged by 
the rapidly increasing interest in Professor Kraepelin' s 
teaching during the past five years in this country and 
the constantly growing number of his disciples, it was 
the author's first intention to publish a complete transla- 
tion of the sixth edition of Kraepelin's " Lehrbuch der 
Psychiatrie." It was feared, however, that a full trans- 
lation would be too large to best subserve the function 
of a text-book, and would have rendered impossible the 
adaptation of the Kraepelin psychiatry to our peculiar 
American needs. 

The classification, terminology, and, wherever possible, 
the phraseology of this work are Kraepelinian, but the 
author has taken the liberty of abbreviating dispropor- 
tionately the description of some psychoses which are of 
less importance to the American physician, especially the 
constitutional psychopathic states and thyroigenous in- 
sanity, and of laying more stress upon other more impor- 
tant forms, the description of acquired neurasthenia, 
traumatic neuroses, also the treatment in epileptic and 
hysterical insanity and acquired neurasthenia. 


The only omissions are the general etiology, diagnosis, 
and treatment in the first volume of Kraepelin, but such 
points as are of most importance have been added to the 
etiology, diagnosis, and treatment of the different diseases. 

The work has been done in the pressure of routine 
duties as Assistant Physician and Pathologist of the Con- 
necticut Hospital for the Insane, and the author begs 
leave to express in this place his grateful appreciation 
of the generous advice and help of his colleagues in the 
hospital, especially Dr. Charles W. Page. He is particu- 
larly indebted to Dr. J. M. Keniston for a general revision 
of the text as well as for the arrangement of the chapter 
on epileptic insanity, to Professor Raymond Dodge, Ph.D., 
of Wesleyan University, for criticism and suggestion with 
regard to the general symptomatology, and to Dr. August 
Hoch and Adolf Meyer for their continued inspiration and 
critical assistance. 



January 15, 1902. 




A. Disturbances of Perception 3 

Hallucinations, clouding of consciousness, disturbance of appre- 

B. Disturbances of Mental Elaboration 18 

Disturbances of memory, disturbances of the formation of ideas 
and concepts, disturbances of the train of thought, disturb- 
ances of judgment and reasoning, disturbances of the rapid- 
ity of thought, disturbances of capacity for mental work, 
disturbances of self -consciousness. 

C. Disturbances of the Emotions 46 

D. Disturbance of Volition and Action 56 


I. Infection Psychoses 73 

A. Fever Delirium 74 

Etiology. Symptomatology. Course. Prognosis. Treat- 

B. Infection Delirium 76 

Pathological anatomy. Symptomatology. Initial deliria, 
delirium of smallpox, typhoid, and hydrophobia. Course. 
Prognosis. Treatment. 

C. Psychoses Characteristic of the Post-febrile Period of Infec- 

tious Diseases 79 

Symptomatology. Simple asthenia, delusional form, stu- 
porous form, polyneuritic psychosis (Korssakow's dis- 
ease). Treatment. 
II. Exhaustion Psychoses 85 

A. Collapse Delirium 85 

Etiology. Symptomatology. Course. Diagnosis. Prog- 
nosis. Treatment. 

B. Acute Confusion al Insanity (Amentia) 90 

Etiology. Pathological anatomy. Symptomatology. 
Course. Diagnosis. Prognosis. Treatment. 




C. Acquired Neurasthenia. Chronic Nervous Exhaustion . 96 
Etiology. Symptomatology. Course. Diagnosis. Prog- 
nosis. Treatment. 
HI. Intoxication Psychoses 105 

A. Acute Intoxications 105 

Organic and inorganic substances : santonin, chloroform, 
atropin, lead. 

B. Chronic Intoxication 107 

1. Alcoholism 107 

Acute Alcoholic Intoxication : Pathological anatomy 107 

Chronic Alcoholism : Etiology. Pathological anat- 
omy. Symptomatology. Diagnosis. Prognosis. 
Treatment 110 

Delirium Tremens : Etiology. Pathological anat- 
omy. Symptomatology. Course. Diagnosis. 
Prognosis. Treatment 115 

Alcoholic Delusional Insanity: Etiology. Sympto- 
matology. Course. Diagnosis. Prognosis. 
Treatment 126 

Alcoholic Paranoia: Symptomatology. Course. 
Treatment 129 

Alcoholic Pseudoparesis : Symptomatology. Course. 
Diagnosis. Pathological anatomy . . . 131 

2. Morphinism 134 

Etiology. Pathological anatomy. Acute morphin 
intoxication. Chronic morphin intoxication. 
Abstinence symptoms. Course. Diagnosis. Prog- 
nosis. Treatment. 

3. Cocainism 141 

Etiology. Acute cocain intoxication. Chronic 
cocain intoxication. Cocain delusional insan- 
ity. Course. Diagnosis. Prognosis. Treatment. 
IV. Thyroigenous Psychoses 146 

A. Myxedematous Insanity 146 

Etiology. Symptomatology. Course. Treatment. 

B. Cretinism 149 

Etiology. Pathological anatomy. Symptomatology. 

V. Dementia Prsecox 152 

Etiology. Pathology. General symptomatology: Disturb- 
ances of apprehension, hallucinations, disturbances of con- 
sciousness, disturbances of attention, disturbances of memory, 
disturbances of thought, disturbances of judgment, disturb- 



ances of emotion, disturbances of conduct, disturbances of 
capacity for mental application, physical symptoms. 

Hebephrenic Form : Special symptomatology, physical symp- 
toms, course, outcome 162 

Catatonic Form : Pathological basis, special symptomatology, 
physical symptoms, course, outcome 173 

Paranoid Forms. First Group: Special symptomatology, 
physical symptoms, course. Second Group : Special symp- 
tomatology, course 188 

Diagnosis. Prognosis. Treatment 196 

VI. Dementia Paralytica 203 

Etiology. Pathological anatomy. General symptomatology: 
Disturbances of apprehension, hallucinations, disturbances 
of consciousness, disturbances of memory, disturbances of 
thought, disturbances of judgment, disturbances of emo- 
tions, disturbances of conduct, physical symptoms. 

Demented Form. Expansive Form. Agitated Form. De- 
pressed Form 225 

Course. Diagnosis. Prognosis. Treatment • 241 

VII. Organic Dementia 249 

A. Diffuse Lesions 249 

Gliosis of cortex. Diffuse cerebral sclerosis. Heredi- 
tary syphilis. Arterio-sclerotic insanity. Encepha- 
litis subcorticalis. Multiple sclerosis. 

B. Localized Lesions 250 

Tumors. Abscesses. Hemorrhages. Embolisms. Throm- 
bosis. Head injury. Insolation. Diagnosis. Treatment. 
VIII. Involution Psychoses 254 

A. Melancholia 254 

Etiology. Pathological anatomy. Symptomatology. 
First Group. Second Group. Physical symptoms. 
Course. Diagnosis. Prognosis. Treatment. 

B. Presenile Delusional Insanity 267 

Etiology. Symptomatology. Diagnosis. Prognosis. 

C. Senile Dementia 273 

Etiology. Pathological anatomy. Symptomatology. 
Simple senile deterioration. Senile confusion. Senile 
delirium. Physical symptoms. Course. Diagnosis. 

IX. Manic-depressive Insanity 282 

Etiology. Pathology. General symptomatology: Disturb- 
ances of apprehension, disturbances of consciousness, hallu- 
cinations, delusions, disturbances of thought, disturbances 



of emotions, disturbances of conduct, pressure of activity, 

pressure of speech, retardation. 
Maniacal States : Hypomania. Mania. Delirious Mania . 291 
Depressive States : Simple Retardation. Retardation with 

Delusions and Hallucinations. Stuporous Conditions . . 299 
Mixed States : Maniacal Stupor. Stuporous Mania . . 305 
Course. Prognosis. Diagnosis. Treatment .... 307 

X. Paranoia 316 

Etiology. Pathological anatomy. Symptomatology. Course. 

Diagnosis. Prognosis. Treatment. Querulent Insanity. 
XI. General Neuroses 329 

A. Epileptic Insanity 329 

Etiology. Pathology. Symptomatology: Epileptic de- 
terioration, transitory periodical ill-humor, dreamy 
states, pre- and post-epileptic insanity, psychic epilepsy, 
epileptic stupor, anxious delirium, conscious delirium, 
dipsomania. Diagnosis. Prognosis. Treatment. 

B. Hysterical Insanity 353 

Etiology. Pathology. Symptomatology: Psychical 
symptoms, physical symptoms, dreamy states. Course. 
Diagnosis. Prognosis. Treatment. 

C. Traumatic Neuroses 371 

Etiology. Symptomatology. Diagnosis. Prognosis. 
XH. Constitutional Psychopathic States 378 

A. Congenital Neurasthenia 378 

Etiology. Symptomatology. Course. Treatment. 

B. Compulsive Insanity 382 

Symptomatology. Course. Prognosis. Treatment. 

C. Impulsive Insanity 389 

Symptomatology. Course. Treatment. 

D. Contrary Sexual Instincts 392 

Etiology. Symptomatology. Diagnosis. Prognosis. 
Xni. Defective Mental Development 397 

A. Imbecility 397 

Symptomatology: Stupid form, active form, moral im- 
becility. Course. Diagnosis. Treatment. 

B. Idiocy 406 

Etiology. Pathological anatomy. Symptomatology. 
Physical Symptoms. Diagnosis. Prognosis. Treat- 



Plate 1. Muscular tension in catatonic stupor producing "Snautz- 

krampf" 176 

Plate 2. Muscular tension in catatonic stupor 178 

Plate 3. Cerea flexibilitas in catatonic stupor 180 

Fig. 1. Catatonic writing 182 

Plate 4. Illustrates the normal pyramidal cell of the cerebral cortex 

and the cytological changes occurring in dementia paralytica . 208 

Plate 5. The normal cerebral cortex ; cerebral cortex in idiocy and 
dementia paralytica ; also the glia in the normal cortex, the pres- 
ence of spider cells in dementia paralytica and their relation with 

the blood-vessels 210 

Plate 6. A group of paretics, illustrating the lack of expression in 

the countenance and the inelastic attitude 220 

Fig. 2. Paretic handwriting 222 

Fig. 3. Paretic handwriting showing partial agraphia . . . 222 

Fig. 4. Paretic handwriting showing complete agraphia . . . 222 

Plate 7. Paretic handwriting 224 

Plate 8. Paretic handwriting 226 

Fig. 5. Senile handwriting 279 

Plate 9. Macrocephaly 406 

Plate 10. Microcephaly 408 

Plate 11. Casts of symmetrical and asymmetrical palates . . 411 





The perception of external sensory stimuli depends 
upon two conditions : the adequate stimulation of the 
sensory end organ ; and the elaboration of this stimulation 
by the central nervous system. 

The loss of one or more of the senses modifies mental 
development in proportion to the importance of the sen- 
sory material lost and the possibility of substituting other 
sensory experience. Loss of sight is relatively unimpor- 
tant, but loss of hearing, on account of its relation to 
language, is of great importance ; indeed, unless specially 
trained, deaf mutes remain mentally weak through life. 

Illusions and Hallucinations 

More important than the mere absence of sensory ex- 
perience is its falsification. 

Inadequate stimulation of the sense organ produces 
impressions corresponding to the " specific energy " of 
that sense ; for instance, an electric current may produce 
a sound, a taste, a tactual or a visual sensation, according 
as it stimulates the corresponding sense organ. Such sen- 
sations are real illusions, but they do no harm because 
they are immediately recognized as illusions. In condi- 
tions of mental disturbance, on the contrary, especially 



The perception of external sensory stimuli depends 
upon two conditions : the adequate stimulation of the 
sensory end organ ; and the elaboration of this stimulation 
by the central nervous system. 

The loss of one or more of the senses modifies mental 
development in proportion to the importance of the sen- 
sory material lost and the possibility of substituting other 
sensory experience. Loss of sight is relatively unimpor- 
tant, but loss of hearing, on account of its relation to 
language, is of great importance ; indeed, unless specially 
trained, deaf mutes remain mentally weak through life. 

Illusions and Hallucinations 

More important than the mere absence of sensory ex- 
perience is its falsification. 

Inadequate stimulation of the sense organ produces 
impressions corresponding to the " specific energy " of 
that sense ; for instance, an electric current may produce 
a sound, a taste, a tactual or a visual sensation, according 
as it stimulates the corresponding sense organ. Such sen- 
sations are real illusions, but they do no harm because 
they are immediately recognized as illusions. In condi- 
tions of mental disturbance, on the contrary, especially 



where there is great clouding of consciousness, the sub- 
jective sensations of light as the result of congestion of 
the eye, or a roaring in the ear, may be interpreted as 
fire or torrents of water, giving rise to genuine deceptions 
which are not corrected. This sort of peripherally con- 
ditioned sense deception has been called elementary, on 
account of its origin in that part of the sensory apparatus 
which receives the stimulus. 

States of consciousness similar to sensory perceptions 
may be produced by the excitation of the so-called cortical 
sensory areas. This is naturally referred to an external 
object, and results in an illusion as to the real source 
of the stimulus. This group of hallucinations may be 
called perception phantasms. They may occur in normal 
individuals, particularly at the onset of sleep, as hypno- 
gogic hallucinations. In abnormal conditions, they are 
often extremely vivid and misleading. They usually 
bear no relation to the content of thought, and, conse- 
quently, seem to the patient to belong to the external 
world. They have a fairly uniform content, subject only 
to slight modification (stable hallucinations of Kahlbaum) ; 
and consist of senseless words, noises, figures, and the like, 
which are repeated over and over again. Because of their 
central origin, they may occur after destruction both of 
the peripheral sense organ and the afferent nerve. 

Peripheral influences may also produce, directly or in- 
directly, conditions of excitation in the higher portions of 
the sensory tracts, which lead to sense deceptions, particu- 
larly if the general irritability of these parts is increased. 
In morbid conditions, ordinary organic stimuli suffice to 
produce such falsification. In other cases, these halluci- 
nations may appear if attention is merely directed to that 
sensory field, or if an emotional condition temporarily 


increases the general susceptibility to stimulation. It 
disappears, on the other hand, as soon as the patient 
becomes quiet or directs his attention elsewhere, as 
in conversation, manual or mental employment, change 
of environment, etc. Further evidence of cooperation of 
conditions of stimulation in the sense organ is found in 
the occasional occurrence of one-sided hallucinations, the 
frequent association of chronic middle ear disease with 
hallucinations of long standing, and the production of 
hallucinations of sight in alcoholic delirium by gentle 
pressure on the eyeball. Usually these sense decep- 
tions appear only in a single sensory field, and are 
most frequent in the fields of hearing and sight. 

Sense deceptions are divided clinically into hallucina- 
tions and illusions. In the former there are no recog- 
nizable external stimuli; the latter are falsifications of 
real percepts. In some cases this distinction may be dif- 
ficult to carry out on account of internal stimulation of 
the sense organs, such as occurs in phosphenes, entotic 
noises, etc. In other cases the distinction is clear. The 
perception of ghosts in moving clouds and limbs of trees, 
curses and threats in ringing bells, are evidently illusions. 
But the well-known visual disturbance of the alcoholic, 
and the voices which torture the condemned in his prison, 
when everything is quiet, are pure hallucinations. 

The universal characteristic of the entire group of sense 
deceptions is their sensory vividness. They depend on the 
same sort of cerebral processes as does normal perception, 
and the false perception takes its place in consciousness 
among the normal sensory impressions without any dis- 
tinguishing characteristic. The patients do not merely 
believe that they see, hear, and feel, but they really see, 
hear, and feel. 


In morbid conditions very vivid ideas or memory images 
may assume the form of hallucinations, being regarded by 
the patients as real perceptions of a peculiar kind. Many 
investigators hold that all false perceptions should be 
regarded as ideas of imagination of extraordinary sensory 
vividness. But in order that an idea attain the clearness 
of a perception, some special cause must be present. This 
is indicated by the fact that in patients suffering from 
hallucinations, not all, but only certain groups of ideas 
seem to play a r61e in the sense deceptions, and besides 
these are usually ideas of the ordinary, faded, and form- 
less type. The element which makes a hallucination out 
of a vivid idea is probably a reflex excitation of those 
central sensory tracts, through which alone normal stimuli 
come to consciousness (the so-called " reperception " of 
Kahlbaum). If it is really these areas of the brain 
through whose excitation perception acquires its peculiar 
sensory marks, it is easy to see how they may participate 
in varying degrees in the active process of renewing 
previous impressions. A view of this sort would explain 
the fact that there lies between the sense deception of 
pronounced sensory vividness and the most faded memory 
image an unbroken series of transition stages. It is pos- 
sible that during the ordinary thought processes this reflex 
excitation or reperception is always present in a very 
slight degree, but that only when the process becomes 
morbid, or the sensory areas themselves are in a condition 
of increased excitability, does the vividness of the memory 
picture approach that of true sense perception. Probably 
there is, moreover, a definite relation between the strength 
of the reperception and the irritability of the sensory areas ; 
the greater their irritability, the more easily will the mem- 
ory images attain sensory vividness, the lighter the reflex 


excitation need be to release them, and the more indepen- 
dent they are of the current of thought. The extreme 
case would be found in the sense deceptions depending 
upon local excitation, which seem to the patient to be 
something quite foreign and external. The extreme case 
in the other direction would be those instances which are 
not true sense deceptions at all, but merely ideas of great 
sensory vividness. By careful investigation it is often 
possible to analyze the data given by the patient, which 
apparently indicated hallucinations, and to discover that 
the patient does not regard the impression as objectively 
real, but merely differentiates it from his ordinary ideas 
on account of its forceful vividness. In these cases it is 
probable that the reperception is strongly developed, while 
irritability of special sensory tracts is not increased. This 
seems to be borne out by the fact that this group of 
hallucinations, which has been variously designated as 
psychic hallucinations (Baillarger), pseudohallucinations 
(Hagen), and apprehension hallucinations (Kahlbaum), 
involves several or all of the sensory fields, and that it 
always stands in close relation to the other contents of 
consciousness ; while the true falsifications of perception, 
on the other hand, usually belong to a single sensory 
tract, and are independent of the train of thought. 

A striking illustration of this type of hallucinations is 
found in a condition called " double thought." Immedi- 
ately upon the appearance of any idea, the patient has 
another distinctly subsequent idea of the same thing ; i.e. 
every idea is followed by a distinct sensory after-image. 
This double thought occurs most frequently when the 
patients are reading, sometimes when writing, and occa- 
sionally, also, when linguistic ideas come vividly to con- 
sciousness. The sensory after-image disappears if the 


words are actually spoken. Other hallucinations of hear- 
ing universally accompany this condition. 

Apperceptive illusions are those in which subjective ele- 
ments unite with the objective sensory data, giving rise to 
a distorted and falsified impression. They are of very 
frequent occurrence in normal life ; prejudice, expectation 
and the emotions, continually influence our perceptions 
even in spite of our earnest effort to be neutral. Even 
the most tranquil scientific observer is never quite certain 
that his perceptions do not unconsciously suit themselves 
to the views with which he approaches his investigation ; 
while in reading we all unconsciously correct the errors 
of the type-setter from the residua of our experience. In 
mental disturbances the conditions are often extraordi- 
narily favorable for this falsification of apprehension. 
Marked emotional excitement, great activity of the imagi- 
nation, and finally, the inability to sift and correct experi- 
ence by reason, — all are favorable to its development. 
Thus, it frequently happens that the sensory impressions 
of patients take on fantastic forms and become the basis 
of a thoroughly falsified apprehension of the external 
world, even when there are no true hallucinations. This 
phenomenon naturally occurs most frequently, both in 
normal and abnormal states, when the sensory impres- 
sions are confused and indefinite, and not readily differen- 

There is an allied group of disturbances which consists 
in the release of a false perception in one sensory field 
through a real impression received by another, constitut- 
ing the so-called " reflex hallucinations of Kahlbaum" A 
sensory stimulus may produce conditions of excitation, 
which, transferred to an over-excited sensory area, occasion 
the development of an hallucination. Similar conditions 


are daily encountered in the so-called sympathetic sensa- 
tions, like the unpleasant sensation of an inexperienced 
onlooker at a painful surgical operation. In morbid con- 
ditions these may be very marked. Especially sensations 
of movement which frequently accompany sense impres- 
sions seem to rise in this way. There are patients who 
feel on their tongues the words spoken by others; a glance 
from some one may excite a sensation of strain. 

A very important characteristic of sense deceptions, 
which in one way points to their origin and in another to 
their importance as a disease symptom, is the powerful 
and irresistible influence which they exert over the entire 
thought and activity of the patient. It is true that occa- 
sionally a pronounced illusion appears in persons mentally 
sound ; and, also, that at the beginning, as well as at the 
end, of a mental disease the illusions are often recognized 
as such, because of their improbable content, but usually 
persistent illusions and hallucinations overpower the judg- 
ment, and ultimately the patients invent the most foolish 
and fantastic explanations to account for them. 

The basis for this irresistible influence is not to be found 
in the sensory vividness of the illusion, since real sensa- 
tions and definite evidence are useless as correctives. Its 
explanation is found rather in the intimate connection 
between the illusions and the patient's innermost thought, 
morbid fears, and desires. The emotional states and the 
feelings color the illusions in a peculiarly high degree, as 
one might expect from their influence in normal life. It 
is frequently observed, especially in the end stages of 
dementia prsecox, that illusions appear only in connection 
with the periodical vacillations of the emotional state, 
while they completely disappear in the interval. This 
influence of the emotional life upon the thought and 


actions only disappears with recovery, or when progres- 
sive deterioration obliterates emotional activity. In both 
cases the illusions may continue, but the patients do not 
react upon them. 

These facts manifestly disprove the general view that 
sense deceptions regularly, or even frequently, act as the 
real causes of delusions. To be sure, patients point to 
their hallucinations as the basis of their symptoms, but 
there can be no doubt that the sense deceptions have a 
common source of origin with the other disturbances of the 
mental equilibrium. In reality the patients attitude 
toward his illusions and hallucinations is not the same as 
his attitude toward his actual perceptions. No healthy 
individual would refer to himself such words as " That 
is the president," and then immediately believe he must 
be the president. But when these words form the key- 
stone of a long chain of secret misgivings, an hallucina- 
tion of that sort makes the most profound impression, 
and immediately there arises a firm conviction, not only 
that the words were really spoken, but that they express 
the truth. 

In view of these facts we see no special practical value 
in distinguishing in single cases whether the delusion, the 
emotional state, or the corresponding sense deceptions 
appear first. In the vast majority of cases, and especially 
where the sense deceptions appear with persistent delu- 
sions, all of these disease symptoms are certainly only the 
result of one and the same common cause. 

Illusions and hallucinations present a large number of 
clinical types in the different sensory fields. The most 
frequent sense deceptions of sight are those which occur 
at night, the so-called visions ; God, angels, dead persons, 
distorted figures, wild animals, and the like. The less 


common sense deceptions of sight which appear in day- 
light along with the normal impressions are much more 
like normal perceptions and consequently more deceptive. 
The sense deceptions of the alcoholics are of this type 
(see p. 115). The objects of the surroundings may take 
on an entirely different appearance; patients mistake 
strangers for relatives and vice versa, and believe that the 
same persons are taking on different forms and faces, are 
making grimaces, etc. 

The most important sense deceptions of hearing are the 
so-called voices, a term which is usually well understood 
by the patient. The basis for their importance lies in the 
fundamental significance of language in our psychic life. 
The voices usually have an intimate relation to the con- 
tent of consciousness ; in fact, they are the linguistic ex- 
pressions of the patient's inmost thought, and for this 
reason have for him a far greater convincing power than 
all other sense deceptions, more even than real speech. 
The voices mock the patient, threaten him, and tell his 
secrets. They are heard in the scratching of a pen, in 
the barking of dogs, etc. Sometimes there are several 
distinct " voices " with characteristic differences. Usually 
they are low, as if coming from a distance, though occa- 
sionally they are loud enough to drown all other noises. 
It rarely happens that the "voices" speak long sen- 
tences. Usually they consist of short, interrupted remarks. 

In some cases there occurs a peculiar rhythmical rise 
and fall of the tone, seeming to have a definite relation to 
the pulsations of the carotid. Auditory sense deceptions 
usually occur in the form of loud shouting and cracking 
noises, ringing of bells, wild shrieks ; but sometimes they 
consist of pleasant music and songs. 

Auditory sense deceptions are seldom indifferent to the 


patients, but are almost always accompanied by strong 
emotional disturbances and wield a powerful influence 
over the patients' actions. They make them distrustful, 
excited, and even drive them to angry attacks on their 
imaginary tormentors. 

The so-called " internal voices" " suggestions/ ' " tele- 
phoning," " telegraphing," etc., form a special group of 
hallucinations of hearing. These naturally are not 
regarded by the patients as sensory in their origin. They 
may occur as a kind of monologue or as a conversation 
with distant persons ; sometimes the voices of conscience 
seem to criticise the patient or spur him on. In all these 
cases the patient develops the delusion that his thoughts 
are known to every one, or that they are produced and 
influenced by outside forces. 

Sense deceptions in the other senses are of much less 
importance. False perceptions of taste, smell, dermal, 
muscular, and general senses, so far as they derive their 
origin from the thoughts of the patient, and not from the 
disturbance of the sense organs, point to a profound change 
of the whole psychical personality. 

Where delusions of electrical influence, of position, of 
incasement of different organs of the body, the disappear- 
ance of the ears, mouth, etc., are present we no longer 
have simple illusions and hallucinations, but almost 
always a severe disturbance of the higher psychical 


Clouding of Consciousness 

External stimuli occasion within us characteristic mental 
phenomena which we apprehend immediately and distin- 
guish as presentations, feelings, and volitions. This 
experience is designated as consciousness which is present 
whenever physiological stimuli are converted into psychic 


processes. The nature of consciousness is obscure, yet we 
know not only that it in general depends upon the func- 
tioning of the cerebral cortex, but also that its individual 
phenomena are connected with definite, but as yet undeter- 
mined, physiological processes in the nervous system. Just 
as the transition of the external stimuli into sensory exci- 
tations depends upon the nature of the sensory organ, so the 
condition of the cerebral cortex is the determining factor 
in the transformation of physiological into conscious pro- 
cesses. Whether such transformation takes place in 
individual cases is often very difficult to determine, since 
we have no immediate insight into the inner experience 
of others and are compelled to draw our conclusions from 
their behavior. 

The condition in which the transformation of physio- 
logical into psychical processes is completely suspended, is 
designated unconsciousness. Every stimulus which crosses 
the threshold of consciousness thereby arousing a psychic 
process must possess a certain intensity which cannot sink 
below a definite limit. This limit is called the threshold 
value and varies greatly according to the condition of the 
cortex. While it is lowest in strained attention, the thresh- 
old value reaches infinity in the deepest coma. It is thus 
possible to distinguish different degrees of the clearness 
of consciousness according to the character of the threshold 
value. But even when conscious processes are no longer 
aroused by external stimuli, consciousness in the form of 
obscure presentations and general feelings may still exist. 

Disturbance of Apprehension 

The vast majority of our impressions at any given 
moment are obscure and confused. Presentations only 
become clear and distinct when they find residua of past 


experience in the memory, " resonators/ ' as it were, 
through whose sympathetic vibration the sensory stimu- 
lation is intensified. It is through this process, which 
Wundt calls "apperception," that each percept becomes 
united with our past experience, through which alone it 
can be understood. This supplementing the given im- 
pression by memory images greatly increases the delicacy 
of our apprehension, but brings with it the danger of a 
falsification of perception. 

Whenever the residua of previous experience fail to 
cooperate in perception, external impressions are not com- 
prehended ; the whole content of consciousness becomes 
less distinct, and there results a clouding of consciousness. 
Even if intense stimuli force their way into consciousness, 
they are not understood, as they have no connection with 
the past. We have a similar experience when we are con- 
fronted by absolutely unfamiliar circumstances to which 
our past gives us no clue. Thus the details of an inverted 
landscape are largely lost to us, although the sensory 
stimuli per se are quite as intense when inverted as when 
right-side up. 

When the memory residua respond only to intense stimuli, 
external impressions can be understood only occasionally 
and with effort. If the disturbance of apprehension is 
still greater, this condition passes over into insensibility 
and lethargy. Ordinary fatigue and its transition into 
sleep present all degrees of this phenomenon. A similar 
disturbance of apprehension is produced by a number of 
hypnotics, such as alcohol, paraldehyde, and trional. It 
is also found in the following morbid states : mental 
exhaustion, fever and intoxication deliria, epilepsy, col- 
lapse delirium, and amentia. Lesser disturbances of appre- 
hension are encountered in manic-depressive insanity. 


Disorientation, in which one is unable to comprehend 
his environment in its temporal and spacial relations 
and the personality of those about him, is possibly a 
special form of a moderate clouding of consciousness. It 
is self-evident that in coma one can no longer comprehend 
his environment. But even when some impressions are 
well apprehended the disorientation may be more or less 
complete. The most striking example of this occurs in 
delirium tremens (see p. 117). Defective orientation is 
always associated with disturbance of apprehension, but 
the converse is not true. On the other hand, orientation 
may be fairly good, while the ability to understand ques- 
tions and orders is lost. The causes of this disturbance 
are probably very complicated. Orientation seems to 
require more elaborate mental processes than does the 
understanding of isolated words, and it is precisely these 
more elaborate processes that seem to be affected most in 
the moderate degrees of clouding of consciousness. All 
of this naturally has no reference to the disorientation 
which is caused by false interpretation of impressions, 
as in delusions, etc. 

Normal consciousness during its development in earliest 
childhood is similar to clouding of consciousness. The 
child lacks the complex memory residua by which present 
experience is interpreted. In the more severe forms of 
defective psychical development this condition remains 
permanent. The consciousness of the idiot is nothing 
but an obscure mixture of isolated, confused presenta- 
tions and indefinite feelings, in which neither clear appre- 
hension, lucid arrangement, or grouping is possible. 

The possibility of active attention and choice of impres- 
sions is the most important result of the influence of the 
memory residua over perception. In a child the content 


of consciousness is helplessly dependent upon accidental 
circumstances ; it receives only the most striking stimuli. 
In adults, on the other hand, the process of perception 
is more and more dominated by personal tendencies which 
gradually develop out of the experiences of the individual. 
We train ourselves to notice certain impressions in prefer- 
ence to others, so that some stimuli, however faint, have 
decided advantage over others. On the other hand, 
we accustom ourselves to be inattentive to regularly re- 
curring stimuli, yielding them no influence over our 
psychic processes. This development of definite "points 
of view," definite directions of interest, leads to an 
extraordinary variability of the threshold of conscious- 
ness, so that in the same moment strong stimuli pass 
quite unnoticed, while we apprehend with greatest acute- 
ness the finest alterations in some special object. This 
ability to concentrate the attention is of the greatest 
importance for the development of the understanding. 

The domination of the attention by accidental external 
influences is called distractibility. The greater the dis- 
tractibility, the less the perception is controlled by the 
inner motives arising from experience, and the less cohe- 
rent and uniform is the conception of the external world. 
Individual percepts are linked incoherently with those 
internal associations which are developed under the in- 
fluence of controlling ideas. Details are apprehended 
without a comprehensive view of their relation, and the 
entire apprehension is superficial. This defect is found in 
children and more or less in some normal adults. The 
extreme form occurs in idiocy. A lesser degree of dis- 
tractibility is found in the absent-mindedness of fatigue. 
Distractibility is more marked in chronic nervous ex- 
haustion, during convalescence from severe mental and 


physical illness, and still more prominent in the acute ex- 
haustion psychoses, also in paresis and dementia praecox, 
while it is especially characteristic of maniacal forms of 
manic-depressive insanity. In these conditions a single 
word or the most casual stimuli suffice to distract the 
attention. Distractibility is not to be confused with 
" hyperprosexia" which consists in the total absorption of 
the attention by a single process, examples of which are 
found in the so-called absent-mindedness of scholars, and 
the complete absorption of the melancholiac in his sad 


The material of experience, received through the dif- 
ferent senses and clarified by attention, forms a basis for 
all further mental elaboration, and it is self-evident that 
both disturbances of apprehension, and the inability to 
make a systematic choice in the impressions, must affect 
to a marked degree the character of all intellectual 


Disturbances of Memory 

All higher mental activity depends largely upon mem- 
ory. Every impression which has once entered conscious- 
ness leaves behind it a gradually fading " disposition " to 
its recall, which may be accomplished either through an 
accidental association of ideas or through an exertion of 
the will. This disposition to recollection is really identical 
with the residua which each new perception contributes 
to the store of experience and to the resources of memory. 
The residua are strong and permanent in direct propor- 
tion to the clearness of the original impression, to the 
multiplicity of its relations to other processes, i.e. to the 
interest it arouses and to the frequency of its repetition. 
The vast majority of our ideas and the greater part of the 
association complexes with which we have to do daily 
are so accessible to us that they appear of themselves 
under the least provocation and without any effort. 

Memory is really a dual process dependent on impressi- 
bility and on retentiveness, each of which may be disturbed 
independently of the other. 



Impressibility is the faculty of receiving a more or less 
permanent impression made by new experience. The 
clear apprehension of events, especially when aided by 
active attention, increases this impressibility, while it is 
lessened by difficulty of apprehension, by distractibility 
and indifference. It, therefore, is diminished wherever 
there is cloudiness of consciousness as in amentia, to a 
less extent in the absent-mindedness of fatigue, and in the 
states of deterioration in dementia prsecox and in epilep- 
tic insanity, which are characterized by stupid indifference 
to the environment. There is also a marked disturbance 
of impressibility in many other diseases, especially those 
with extensive lesions, paresis, senile dementia, and Kors- 
sakow's disease, although the moment impressions are 
well apprehended and assimilated. In normal life it is 
the greatly diminished impressibility which renders it 
difficult to recall our dreams. This demonstrates that 
psychic life, and therefore consciousness, can exist with- 
out memory. Similar conditions of clouded conscious- 
ness, with undoubted evidences of a psychic activity, but 
yet without memory, occur in epilepsy, many delirious 
conditions, profound intoxications, and hypnotism. " Ret- 
rograde amnesia," in which memory is more or less per- 
manently destroyed without clouding of consciousness, 
occurs in epileptic, hysterical, and paralytic attacks, head 
injury, and some attempts at suicide, in which patients 
cannot remember the events which immediately precede 
the attack. Memory for this period may return. 

Retentiveness of memory for past events depends upon 
the previous impressibility, upon repetition and the native 
tenacity of the individual memory. Its disturbance is 
manifested by an inability to accurately recall former 
knowledge and important personal events. Lack of im- 


pressibility usually accompanies lack of retentiveness, but 
the converse is not necessarily true, as impressibility is 
affected by clouding of consciousness, while retentiveness 
is not. In senility the former is far more disturbed than 
the latter; recent events leave no residua, while remote 
events recur in memory with ease and accuracy. This is 
even more striking in senile dementia and may occur in 

Our experience is usually retained in memory in a tem- 
poral series reaching back from the present into the past, 
in which only recent events are remembered distinctly; 
while the rest is grouped around more or less isolated 
points which form the basis for the general chronological 
arrangement of our experience. Disturbances of the tem- 
poral arrangement of experience are frequently encountered 
in mental diseases. They are usually more or less pro- 
nounced in paretics and in the severer cases of senile 
dementia, to whom months often seem like days. On the 
other hand, the image of the immediate past fades so 
quickly that it appears as remote as the events which 
happened months ago. 

Finally, the accuracy of memory may be disturbed. 
Even in normal conditions, accuracy is only relative. 
In morbid change of personality or the emotions, and in 
the development of delusions, the past is always more or 
less falsified. Vivid imagination and pronounced egoism 
imperceptibly modify the memory of past experience even 
in normal life; stories are embellished with interesting 
details, while the self becomes a more and more impor- 
tant factor. This is always exaggerated in disease, while 
in melancholia, persecutory and expansive delusions often 
color the memory of the past until it seems like pure 


A mixture of invention and real experience is called 
paramnesia. There also exist "hallucinations of mem- 
ory" (Sully), which consist of pure fabrications, being 
found especially in paresis, paranoid dementia, and some- 
times also in maniacal forms of manic-depressive insanity. 
These are often fantastic accounts of wonderful adven- 
tures ; they may be modified by suggestion and are 
frequently self-contradictory (see p. 215). The delusion of 
a double existence may be produced by confusing present 
experience with indistinct memory images of the past, so 
that every event seems like a duplicate of a former 
experience. This sometimes occurs transiently in normal 
life; in disease it may last for months, and is found 
particularly in epilepsy. 

Disturbances of the Formation of Ideas and Con- 

Most of the complex ideas of normal life are composed 
of heterogeneous elements, furnished by the various senses. 
In these complexes the importance of the material fur- 
nished by any one sense depends upon the peculiarities of 
the individual. For some, vision is the most important 
sense, for others, audition ; but both of these senses may 
be entirely lacking without preventing a high develop- 
ment of ideation. On the other hand, lack of permanence 
of sensory impressions and imperfect assimilation always 
interfere with the formation of complex ideas. This is 
illustrated in congenital and acquired imbecility. 

The formation of concepts is the necessary condition for 
the fullest development of ideation. In normal life those 
elements of experience which are often repeated impress 
themselves more and more strongly, while the accidental 
variations of each individual experience are driven more 


and more into the background. The concepts thus devel- 
oped are a sort of composite photograph or generalization 
of experience. 

These concepts are the most permanent and most easily 
reproduced of all our ideational processes. But even these 
may not be reproduced in totality. More and more in the 
developed consciousness single elements of these concepts 
are made to stand for the whole. The exact form of this 
abbreviation of thought is often accidental, as when some 
single image comes to stand for the total concept. The 
highest form of this development is found in the abbrevia- 
tion of thought by the use of linguistic symbols, i.e. when 
a word stands for the idea. 

In morbid conditions, especially in congenital imbe- 
cility, this development may stop at any point. The 
patients may cling to individual experience without being 
able to sift out the general characteristics of different 
impressions of a similar nature. They are unable to find 
concise expressions for more extended experience ; the 
essential is not distinguished from the unessential, the 
general from the particular. 

This not only prevents the development of thought, but 
it also retards the assimilation of new material. New 
impressions find no point of attachment in the mental 
life ; they cannot be arranged or systematized, and pass 
rapidly into oblivion. In acquired imbecility the residua 
of earlier experience may partly conceal the inability to 
receive new impressions and to form new ideas. Later, 
however, this defect gradually becomes more evident. 
Similarly in paresis, dementia praecox, and senile dementia, 
the circle of ideas narrows, and general ideas and concepts 
are gradually replaced by the specific, the immediate, and 
the tangible. New impressions are no longer elaborated 


and the most recent experience is quickly forgotten, while 
the memory of the past is still fairly constant. 

In direct contrast to this is the disturbance produced 
by morbid excitability of the imagination, which correlates 
dissimilar and even contradictory ideas. Such forced and 
arbitrary combinations naturally interfere with the normal 
development of concepts. Thus the foundation of all 
higher mental activity becomes a mass of confused and 
indistinct psychic structures, which can give rise only to 
one-sided and mistaken judgments as soon as the patients 
leave the region of immediate sensory experience. The 
tendency to reveries and dreams, lack of appreciation of 
facts, impossible plans and chimeras, so often found in 
imbecility, paresis, and paranoid dementia, are clinical 
forms of this disturbance. 

Disturbances of the Train op Thought 

The association of ideas may be divided into two groups : 
external and internal associations, the former being effected 
by purely external or accidental relations, while the latter 
arise from a real coherence in the content of the ideas. 

External associations usually arise through the custom- 
ary connection of ideas in time or space, of which thun- 
der and lightning is an example ; or through habits of 
speech, in which a definite association of words becomes so 
fixed by frequent repetition that one word always calls up 
the others, as in quotations and stereotyped phrases. 
Sound associations, an important and extreme form of 
this type, are based either upon similarity of sound or of 
the movements of the vocal organs, as seen, for example, 
in a morbid tendency to rhyme. This disturbance may 
be so marked that the associated sounds are altogether 


Internal associations depend upon the logical arrange- 
ment of our ideas according to their meaning. The asso- 
ciation between different individuals of the same species, 
or different species of the same class, is of this kind ; for 
instance, the association of boy with man and man with 
animal, etc. The special form of internal associations, 
which emphasize some particular characteristics of a con- 
cept, usually attributes, states of being, or activities, by 
means of which a preceding idea is more closely defined, 
is called predicative association. That the dog is an 
animal belongs to the first class of internal associations ; 
that he is dark-colored, or that he runs, belongs to the 

Paralysis of thought, the simplest form of disturbance 
of the train of thought, is characterized by complete 
absence of all associations. It begins as a more or less 
marked retardation, and develops into characteristic mo- 
notony and distractibility of thought. It occurs in a 
moderate degree in fatigue. Narcotic poisoning presents 
severer forms. It is a fundamental symptom in the psy- 
choses accompanied by deterioration : paresis, dementia 
praecox, and senile dementia. 

Retardation of thought is manifested by difficulty in the 
elaboration of external impressions ; the train of thought 
is markedly retarded and the control of the store of ideas 
is incomplete. It may bring the train of thought to a com- 
plete standstill. In contrast to the paralysis of thought, 
to which it presents a superficial similarity, this inhibition 
may suddenly disappear under certain conditions, as fear. 
The patients do not lack mental ability; they are not, 
like the weak-minded or deteriorated, obtuse and indiffer- 
ent, but they are unable to overcome this restraint which 
they themselves very often realize. The most pronounced 


form of this disturbance is seen in the depressed and 
mixed forms of manic-depressive insanity, and perhaps, 
also, in the disturbance of thought in epileptic stupor. 

The disturbances of the content of thought are best 
understood as a faulty arrangement of the individual links 
of our thought with relation to the goal ideas. Normal 
thought is usually directed by definite goal ideas, and of 
the ideas which appear in consciousness, those elements 
are specially favored which stand in closest relation to 
these controlling goal ideas. Out of the large number of 
possible associations those only really occur which lie in 
the direction determined by the general goal of the 
thought process. 

In morbid conditions the train of thought may be inter- 
rupted by individual ideas, or other trains of thought with 
an especially prominent emotional tone (cf . Melancholia, 
p. 260). 

Compulsive ideas are those ideas which irresistibly force 
themselves into consciousness. These are usually accom- 
panied by a disagreeable feeling of subjection to some 
overwhelming external compulsion. The mere fear of 
their recurrence is often sufficient to bring them into 
consciousness. They usually develop on a basis of emo- 
tional disturbance, and, therefore, accompany melancholia, 
and especially depressed forms of manic-depressive insan- 
ity; while the most favorable condition for their devel- 
opment is hereditary degeneracy (see Compulsive Insanity, 
p. 382). 

Distinguished from the compulsive ideas are the simple 
persistent ideas, unaccompanied by marked unpleasant 
feelings. This phenomenon is probably due to the ab- 
sence of definite or fixed goals in the train of thought, — a 
view which is borne out by our experience with the per- 


sistence of some of our own ideas, whenever we give free 
rein to our thoughts. Rhyme, verses, and melodies 
sometimes cling to us even in spite of our efforts to throw 
them off. Since the content of such persistent ideas is 
wholly accidental, it is probably not the special peculiari- 
ties of the individual ideas which determine its persists 
ence, but rather the entire mental condition. 

Catatonic patients present this disturbance especially 
during the period of excitement, when they incessantly 
repeat isolated words or phrases, or weave them into more 
or less incoherent trains of thought. One patient re- 
peated for twenty-four hours, " Daddy don't, daddy don't." 
Another repeated: " Oh — oh — oh — We are the Wall 
Streets of New York. Oh — oh — oh — look at the clams 
that we get on 33d Street, New York City. Oh — oh — oh 

— he ain't doing a thing but spending his money. Oh 

— oh — oh — and I'm going home. Oh — oh — oh — and 
I ain't going to stay here any longer. Oh — oh — oh — 
they got a big thing down there. Oh — oh — oh — drop 
your money in the slot and you will get all that's coming 
to you. Oh — oh — oh — he will never get that little 
racket. Oh — oh — oh — Yale College don't do a thing," 

Persistence of ideas in definite trains of thought is dif- 
ferentiated from compulsive ideas by the fact that in the 
former the ideas are not accidental, but are based on the 
fixed residua of previous experience. Our whole mental 
development depends upon associations of ideas gradually 
fixed by frequent repetitions, which serve as a basis for 
further mental elaboration. In this way we come to 
depend upon a large number of phrases and fixed associa- 
tions, which inevitably follow the appearance of certain 
cues, not only without our volition, but even against it. 


In morbid conditions, even when the collection and 
elaboration of new impressions is prevented by mental 
disease, there remain some residual ideas of the normal 
state, fixed by constant repetition. This results in a 
monotonous content of consciousness with a marked 
impoverishment of the store of ideas. This occurs in 
senility, paresis, and other deterioration processes, in 
which the train of ideas may shrink down to a few 
phrases, or even a few words which are repeated over and 
over. These phrases in contrast to the persistent ideas of 
the catatonic are not senseless, but actually express the 
content of the patient's consciousness. The following is 
an example : u Frazier went away this morning, will be 
back soon. Didn't ask him what time he'd come home. 
Frazier is working up in the lot at something. I was up 
in the lot yesterday. I forget what I went for. Frazier 
is talking of selling the place. He asked me what I cared 
about it. Father is going over there to-day. Father 
don't care for the farm. He didn't speak to me ; he is 
downhearted. He should bring up his boys to work 
upon it. Frazier don't have time to work. He don't 
stay home much. I would advise them to have a place 
and keep it. If I get well I will keep it, if I can. The 
boys would like to have some farm. They won't stay in 
a place. Frazier don't like to work on the farm. [Patient 
hears a woman coming up the hall.] Some woman I hear 
coming. If she was on a farm, she wouldn't handle much 
money. If they sell the place, the children will starve for 
hunger. [Patient looks at her hand.] I am all blacked 
up. I have been out on the farm a good deal. If he sells 
the place, the little children will starve for hunger," etc. 

Circumstantiality is the interruption of the course of 
ideas by the introduction of a great multitude of non-es- 


sential accessory ideas, which both obscure and delay the 
train of thought. The disturbance depends upon a defec- 
tive estimation of the importance of the individual ideas 
in relation to the goal ideas. The goal may, indeed, be 
ultimately obtained, showing some real coherence, but 
only after many detours. The simplest form of circum- 
stantiality appears in the prolixity of the uneducated, 
who are unable to arrange their general ideas in accord- 
ance with their importance, and show a tendency to 
adhere to details. Some even have difficulty in distin- 
guishing sharply what is actually seen from what is sim- 
ply imagined. The circumstantiality of the senile is 
probably due to the disappearance of the general ideas 
and concepts. Circumstantiality is also present to a 
marked degree in epileptic insanity, of which the follow- 
ing passage taken from the bibliography of an epileptic is 
an example : — 

" Before one believes what others have told him or what 
he has read in the almanacs he must be convinced and 
examine himself before one can say and believe that a 
thing is beautiful or that a thing is not beautiful; first 
investigate, go through it yourself, and examine it, and 
then, when man has investigated everything and has gone 
through it himself and examined it, then man can at once 
say the thing is beautiful or is not beautiful or not good ; 
therefore, I myself say, if one will make a statement 
about a thing, or will sufficiently establish something or 
will speak in conformity with the truth, the thing is right 
or is not right, so must every man likewise examine the 
thing as he believes himself responsible before the tribune 
God, and before his Majesty, the King of Prussia, William 
the Second, and the Emperor of Germany. I will now 
relate further what the soldiers have done to me." 


The absence or incomplete development of goal ideas 
gives rise clinically to two important forms of disturbance 
of the train of thought : (1) flight of ideas, (2) desultori- 
ness. The first effect of a defective control over the train 
of ideas is a frequent and abrupt change of direction. The 
train of thought will not proceed systematically to a defi- 
nite aim, but constantly falls into new pathways which 
are immediately abandoned again. The impetus for such 
changes of direction can arise from both external stimuli 
and from internal processes. 

In flight of ideas the instability of goal ideas produces 
a condition in which the successive links of the chain of 
thought stand in fairly definite connection with each other, 
but the whole course of thought presents a most varied 
change of direction. The patient is unable to give long 
answers to questions, and cannot be held to a problem 
requiring much mental work, because ideas once aroused 
are immediately forced into the background by others. 
This is a fundamental symptom of the maniacal form of 
manic-depressive insanity, and also occurs in acute exhaus- 
tion psychoses, infection deliria, paresis, occasionally also 
in fatigue of normal life and especially in dreams. It may 
appear in alcoholic intoxication. There is no great wealth 
of ideas, but on the contrary it is often accompanied by a 
conspicuous poverty of thought. Moreover, the rapidity 
of the association of ideas is not at all increased, but on 
the other hand is usually diminished. The patient's 
incoherence, therefore, depends simply on the lack of that 
unitary control of the association of ideas which represses 
all secondary ideas and permits progress only in a definite 
direction. As the result of this, any accidental idea which 
would normally inhibit the goal idea may assume impor- 
tance. It is not, then, the rapid succession of ideas which 


warrants the designation of a flight of ideas, but the insta- 
bility of single ideas which are unable to exert any influ- 
ence over the course of the train of thought. 

In flight of ideas the direction of the train of thought 
is determined by external impressions, chance ideas, or 
finally by simple associations, external or internal. The 
influence of chance ideas is well demonstrated in intoxica- 
tion deliria, and especially in opium intoxication, in which 
vivid ideas of the imagination follow each other in a 
variegated series, giving rise to an incoherent progression 
of unrelated fancies, to which experience offers no key. 
This might be called the delirious form of flight of ideas. 

The rambling thought of the hypomaniacal patient is 
another form of the flight of ideas in which the patients 
are diverted by unimportant ideas, reminiscences, and 
incidents, and need to be frequently led back to their sub- 
ject. The following is an example (the patient being 
asked when she left the Hartford Retreat) : " My mother 
came for me in January. She had on a black bombazine of 
Aunt Jane's. One shoestring of her own and got another 
from neighbor Jenkins. She lives in a little white 
house kitty corner of our'n. Come up with an old green 
umbrella 'cause it rained. You know it can rain in Janu- 
ary when there is a thaw. Snow wasn't more than half 
an inch deep, hog-killing time, they butchered eight that 
winter, made their own sausages, cured hams, and tried 
out their lard. They had a smoke house. [But how about 
your leaving Hartford ?] She got up to Hartford on the 
half-past eleven train and it was raining like all get out. 
Dr. Butler was having dinner, codfish, twasn't Friday, he 
ain't no Catholic, just sat with his back to the door and 
talked and laughed and talked." Here, in spite of many 
diversions, we see a fairly good sequence in the content of 



thought which centres around a visit of the patient's 

In the following example, on the other hand, the pre- 
dominance of motor speech ideas has led to a massing of 
habitual speech associations, combinations of common 
words, and finally to simple sound associations. It might 
be called an external flight of ideas in contrast to an 
internal flight of ideas characterized by internal associa- 
tions. " I was looking at you, the sweet boy, that does 
not want sweet soap. You always work Harvard for 
the hardware store. Neatness of feet don't win feet, 
but feet win the neatness of men. Run don't run west, 
but west runs east. I like west strawberries best. Rebels 
don't shoot devils at night." The train of thought is sup- 
planted by fixed and familiar phrases, in which the influ- 
ence of linguistic ideas clearly outweighs that of the 
content of thought ; while sound associations, rhymes, and 
quotations, etc., stifle all internal associations. The most 
favorable condition for the appearance of this form is an 
increased motor excitability and alcoholic intoxication. 

Desulto? % iness, the second form of this type of incoherent 
speech, is more difficult to characterize, as it is not well 
understood. In it the external form of speech is fairly 
well retained, but there seems to be a complete loss of goal 
ideas, while an incoordinate mass of ideas follow each 
other aimlessly and abruptly. In the flight of ideas we 
were able to discover some connection, if only the most 
external, between the separate links of ideas, which gradu- 
ally led to a new chain, until the original standpoint was 
entirely lost sight of. In desultoriness there is no recog- 
nizable association between the successive ideas, while the 
trains of thought often move along for some time in simi- 
lar phrases. They are confused and contradictory. In 


flight of ideas the course always tends toward changing 
and hence never attained goals, and is, therefore, always 
entering new circles ; in this form, on the other hand, the 
train of thought does not progress at all in any one direc- 
tion, but only wanders with numerous and bewildering 
digressions in the same general paths. Distractibility 
through internal and external influences may also be 
present to a marked degree, but the newly aroused ideas 
do not serve as bases for others, but simply intrude into 
the desultory train of thought in an incoherent manner. 
In this way it is often possible, in the midst of their inco- 
herent jumble, to obtain coherent replies to questions. The 
following is an example of this (the physician's ques- 
tions are enclosed in brackets) : " [Why are you here ?] 
Because I am the empress. The dear parents were already 
there and everything was already there and had given me 
permission. I have also learned stenography. Why, David, 
how are you ? Even a member of the reserve, megalomania, 
empress. [Do you feel well ?] Oh, thanks, very well, since 
the government has given me permission we will be good 
friends. Oh, God ! my brother, Carl David the first and 
Olga. Ah, let me write something. [Why are you here ?] 
Insane. Megalomania. [What is that ?] Nothing, noth- 
ing at all. [How old are you ?] 22-7-1872. [Will you 
come again ?] I do not know. When he comes I will not 
run after him (laughs). I must always be close (claps her 
hands). I have nothing (grasps at the watch chain). 
But the chain is nothing. Now I will at once see what 
time it is." This example does not show, however, the 
repetition of single words or phrases which so frequently 
occurs in the catatonic productions, and is shown in the 
following: "You don't own this building, I know that. 
The Hartford pigpen never supported, never confirmed 


food, therefore are not supported and this building will 
pay for that and food which confirmed it. White immor- 
tal eternal receipt for that food. The war planet Mars. 
I have the white immortal eternal receipt. Mars war 
planet, or war world Mars. The war world or the war 
planet Mars. White immortal eternal receipt for its 
existence and confirmation receipt. The Hartford pigpen 
is not supported or has not confirmed food or the laws of 
food, therefore will not be supported by those who have 
confirmed food. The white immortal eternal receipt." 

In extreme desultoriness the speech consists of a mere 
series of letters, syllables, or sounds, while in the severest 
forms of flight of ideas there is always some goal idea even 
though it rapidly changes, and the majority of the expres- 
sions consist of actual words; here there is a perfectly 
senseless repetition of the same sounds with only insignifi- 
cant modifications, like the following : " Ellio, ellio, ellio 
altomellio-altomellio, — selo, eloo, devo, heloo — f . f . f . dear 
father, f. f. f. dear father, e. e. f. old and new — f. f. f. — 
f . f . — Catholic Church," and so on in monotonous repeti- 
tion. Sound associations seem to play an important role 
here, but the train of thought does not advance through 
it to new ideas. 


Disturbances of Judgment and Reasoning 

Judgment and inference are the most complex products 
of the intellect. Since perception, memory, the formation 
of concepts, and the association of ideas are their necessary 
preconditions, they will be more or less affected by every 
imperfection of these processes. But this is not the only 
source of their derangement. 

Human knowledge has two sources ; experience, and the 
free action of the mind itself (imagination). Neither 


source is entirely independent of the other: empirical 
knowledge is never free from preconception and expecta- 
tion, while even the wildest imagination employs material 
which originally came from experience. Nevertheless, we 
sharply differentiate empirical knoivledge from pure belief, 
which arises from the recasting and interpretation of 

Primitive people do not draw this distinction. Their 
mythological interpretations and traditions are as credible 
to them as direct experience. Even in children invention 
and experience are sometimes only partially differentiated. 
Whenever invention can be easily tested by direct experi- 
ence the line between the two becomes more and more 
sharply defined, but even here the natural incompleteness 
of our apprehension or our habits of thought may lead us 
into error. If the data furnished by experience is scanty 
or unreliable, imagination is free to fill the field with its 
own creations. 

Empirical science has slowly supplanted many of the 
misconceptions of primitive thought, but superstition still 
survives among the uncultured ; while even among the 
cultured there are beliefs which no experience or arguments 
can shake. The essential characteristic of these beliefs 
is their emotional significance for the individual. Dog- 
matic opinions, ideas firmly fixed by tradition, education, 
and habit, acquire an overwhelming emotional value, and 
not only persist in spite of experience, but even mould 
experience into conformity with themselves (cf . the force 
of prejudice) . The emotional significance of such beliefs 
has its basis in their relation to vital interest. A feeling 
of helpless dependence and insecurity in the presence of the 
unknown and mysterious is the fertile soil of superstition 
in primitive races. Even in most highly cultured persons 


political and religious convictions, although more or less 
dependent on the rational elaboration of experience for 
their content, are characteristically inaccessible to opposi- 
tion and argument. 

These peculiarities of normal thought help us to under- 
stand the delusions of diseased consciousness. Delusions 
are morbidly falsified beliefs which cannot be corrected 
either by argument or experience. They do not arise from 
experience or deliberation, but from belief. Although 
often associated with actual and falsified perceptions (hal- 
lucinations or illusions), they are always due to a morbid 
interpretation of the events arising in the patient's own 
imagination. The tendency so often encountered in health, 
to draw sweeping conclusions from insufficient data or to 
assume a causal relationship between purely accidental 
occurrences, becomes an important factor in morbid condi- 
tions ; the most innocent events are construed as mystic 
symbols of secret occurrences, and simplest facts are full of 
mystery. The flight of a bird is an omen of good fortune ; 
an accidental gesture reveals sudden danger. 

Further proof of the subjective origin of delusions is 
found in the close relation which they maintain to the 
ego of the patient. Just as in health the self forms 
the point of reference for our thoughts and feelings, so 
in disease the mysterious creations of the imagination 
are most intimately connected with the patient's own 
welfare. The delusions are, consequently, never indif- 
ferent to the patient except in cases of advanced deteri- 
oration. They are not only referred to the self, but 
they exercise a marked influence over the patient's 
emotional attitude toward his environment. 

Delusions are inaccessible to argument, because they do 
not originate in experience. Experience, therefore, is 


unable to correct them as long as they remain delu- 
sions. Only in convalescence, when they become a mere 
memory of delusions, can they be recognized as false. At 
the height of the disease they are as firmly established as 
reason herself. So long as the morbid conditions which 
give rise to them persist, the delusions are unchanged. 
If they are relinquished or modified, the change is not 
due to argument, but to a change in the morbid condition. 
Our argument may drive the patient to admit non-essential 
points, but the delusion serenely reasserts itself, notwith- 
standing the most evident self-contradiction. Even when 
the external object of reference or support is destroyed, a 
new one is quickly found. The delusion needs no other 
support than the absolute conviction of the deluded. 

Vivid emotional states, such as fear, sorrow, anger, joy, 
and enthusiasm are important factors in the origin of 
delusions. Even in health, anxiety and enthusiasm create 
for us, in the consideration of any subject, fears and hopes 
which really have nothing to do with the subject matter. 
In morbid conditions, sorrow and fear exert the strongest 
influence on the falsifications of ideas. 

Clouding of consciousness is sometimes a factor in the 
development of delusions, especially in delirious states. 
Delirium tremens and fever delirium, for instance, pre- 
sent a host of fantastic delusions with but very little 
emotional disturbance. Moreover, delusions which are 
firmly believed one day may be recognized as false the 
next, clearly indicating a morbid condition of conscious- 
ness, which rendered their correction impossible. We 
have an example of this in dreams, where we are unable 
to detect or correct those contradictions which are per- 
fectly clear to us on awakening. Without doubt, there- 
fore, we must regard the clouding of consciousness as an 


essential preliminary condition for the development of 

In paresis, senile dementia, and dementia praecox delu- 
sions appear in which neither emotions or disturbances of 
consciousness play a prominent role. The psychic weak- 
ness, which is a prominent symptom in these diseases, 
seems to favor the development of delusions. But con- 
genital mental weakness shows only a slight tendency 
to the development of delusions, and likewise many cases 
of senile, paralytic, and precocious dementia run their 
course without delusions. The real cause for the delu- 
sions cannot, therefore, lie in the psychic weakness of it- 
self, but only in the accompanying conditions of excitation, 
which permit all sorts of delusional fancies to spring up in 
the patient's mind. It can be easily demonstrated that 
delusions originate most freely during heightened or 
depressed moods. 

Another source of delusions may perhaps be found in 
those peculiar ideas which in health are accustomed to 
occasionally "pop" into our heads, and whose origin 
we are unable to account for. While they have no power 
over us, for the patient, on the other hand, they bear the 
stamp of absolute certainty, even though soon changed 
for others. They often intrench themselves firmly in 
their thoughts and dominate experience, feeling, and 

After this preliminary consideration of all the facts 
relative to the origin of delusions, we are led to the 
assumption that the essential factor is an inadequate 
functioning of judgment and reason. In health we are 
accustomed to judge all our fancies according to the 
standard of our own past experience, and to regard as 
invention that which does not conform to our knowl- 


edge. The patient either does not perceive the contra- 
dictions between his fancies and his former experience, 
or he disregards it and hides it under assumptions which 
are even more fanciful. Clearly the patient has lost, not 
only the impulse, but the power, to oppose, correct, or 
suppress his delusions. The cause of this disability was 
formerly sought in the peculiar attributes of the in- 
dividual ideas. The doctrine of " monomania/ ' which 
held that the " fixed idea " was only a circumscribed dis- 
turbance of an otherwise healthy psychic life, was based 
upon this assumption. 

The development of delusions is thus seen to be based 
on the general disturbance of the entire psychic life. They 
are probably incited by emotional fluctuations which trans- 
form slumbering hopes and fears into imaginary ideas. 
But the fact that these ideas become delusions and acquire 
a power which even the senses cannot destroy, can only be 
explained by an inadequate functioning of judgment, depend- 
ent on impassioned emotional excitement, clouding of 
consciousness, and weakness of the reasoning power. 

The character and duration of delusions differ accord- 
ing to their mode of origin. Those which originate in 
emotional disturbances change with the patient's mood, 
and usually disappear with the emotional disturbance. 
Delusions of delirium, which are determined both by 
clouding of consciousness and emotional disturbances, are 
variegated fantastic pictures recurring in manifold forms, 
with little or no mental elaboration or coherence. They 
likewise disappear with the clearing of consciousness and 
the subsidence of the emotional disturbance. Delusions 
depending both upon mental deterioration and upon 
emotional disturbances do not vanish with the fading 
of the emotional states. They are gradually forgotten, 


but are never corrected by reason. Such delusions occur 
in paresis, dementia prsecox, and senile dementia. In these 
psychoses the forgotten delusions may reappear for short 
periods during emotional exacerbations. With continued 
moderate emotional excitement delusions may be firmly 
held and even elaborated, as in the paranoid forms of 
dementia prsecox. 

Persistent delusions are of two types, the unsystematized 
and the systematized. The former may ultimately disap- 
pear, as in dementia prsecox, end stages of chronic alcohol- 
ism, paresis, and senile psychoses, or they may become 
permanent through frequent repetitions, without system at i- 
zation, as in the paranoid form of dementia prsecox. The 
progressive and uniform systematization of the delusions 
without marked mental deterioration constitutes paranoia 
in the strict sense of the word. In this form the delusions 
become the basis of a thoroughly elaborated, but falsified, 
apprehension of self and the environment ; but even here 
a decided weakness of judgment is probably always de- 
monstrable. The somewhat similar system of coherent 
delusions, sometimes found in paresis and dementia prse- 
cox, are always of shorter duration. 

Practically all delusions centre in the self, either as 
self-depreciation (depressive delusions) or as self-aggrandize- 
ment (expansive delusions). Among depressive delusions, 
those of self accusation stand closest to the normal life. 
Many normal patients torment themselves with the belief 
that they are unlucky. In states of morbid depression 
this idea of guilt may be associated with the patient's 
every action. He believes that he is constantly injuring 
and deceiving others ; his past appears to him as a mass 
of abominable deeds and terrible crimes. He is an irre- 
deemable, unfeeling creature, repudiated by God and 


damned, and is consequently about to suffer a fitting 
punishment, arrest, the scaffold, the stake, or whatever else 
his ingenuity can invent. 

Related to these delusions are the general fears of pov- 
erty, loss of work, or some other misfortune about to befall 
themselves or relatives. In progressing mental weakness 
this form of delusions may become nihilistic, when every- 
thing, the patient included, is non-existent or less than 
nothing. A large group of depressive delusions are those 
of persecution. They originate during periods of indispo- 
sition, discomfort, or anxiety. Mistrust and suspicion are 
excited by peculiar coincidences and misinterpreted re- 
marks. Newspaper articles and popular songs contain 
references and even indirect insults. All assertions of 
love and friendship are disbelieved. At this time, also, 
there usually appear hallucinations, especially auditory. 
The patient sees himself involved in a network of secret 
hostilities and imminent dangers which he cannot escape. 
All are joined against him and gloat over his misery. 
Men call after him, whisper to each other, shun him, spit 
in front of him, etc. Food and drink have a peculiar 
taste, as if poisoned, etc. 

Delusions of jealousy also play a prominent role. The 
patient notices a coolness in marital relations, detects 
fond glances and secret signs, finds in letters arrange- 
ments for secret meetings. The wife is embarrassed by 
his unexpected return home, tries to conceal something, 
coughs in a significant manner, the room is darkened. 
Outside some one pounds on the door, a form scurries by 
the window, the last child does not resemble its father, 

In advanced mental weakness the persecutory ideas 
often assume a very fantastic form. Absurd somatic delu- 


sions of transformation and witchery, such as telepathy, 
magical, electrical, or hypnotic influences, are common 
forms. Sexual delusions are especially common, varying 
from mysterious sexual excitation to imagined childbirth 
during stupor. All these evils may be attributed to any 
individual or group of individuals from the neighbor or 
husband, to the Freemasons or Social Democrats. 

In hypochondriacal delusions the object is some incurable 
disease. Harmless physical symptoms are regarded as 
signs of syphilis, sexual excess, paresis, etc. With the 
onset of deterioration the delusions become absurd and 

Expansive ideas may also be referred to a somatic basis. 
Thus, feeble paretics extol their beautiful voice, their gym- 
nastic dexterity, although they cannot produce a single 
musical tone or even stand on their feet. Closely con- 
nected with the hypochrondriacal ideas are such expansive 
ideas as that the excretions are gold, the urine, Rhine 
wine, etc. Sometimes delusions with a depressive content 
acquire the significance of expansive ideas. Patients state 
that they will die at once in order to be translated to 
heaven; they send invitations to their own execution, 
which is to be conducted with great pomp. 

The delusion of mental soundness in spite of deep-seated 
mental disease, constitutes an absence of insight into the 
disease. This absence of insight is almost universal in 
morbid states ; many patients not only consider themselves 
perfectly sane, but remarkably intelligent, as in paresis 
and paranoia. The external relations of the patients, the 
social position and property, are similarly transformed by 
expansive delusions. Noble descent, close relation to the 
temporal and spiritual authorities, even association with 
supernatural powers, are among the most frequent forms. 


With further development the patient becomes the Presi- 
dent, the Pope, Christ, or God. On the other hand, 
patients boast of their untold wealth and vast estates, 
including whole continents or the world itself, while vague 
plans of gigantic undertakings fill their minds. 

Depressive and expansive delusions are by no means 
mutually exclusive. They may co-exist or follow one 
another very closely. The victim of persecutory delusions 
discovers an inadequate cause of this persecution in ex- 
ceptional ability, natural right to great possession or 
high positions. His detention is the result of jealousy or 
intrigues. These relations are not the result of logical 
elaboration, but rather spontaneous and independent con- 
sequences of the internal condition of the patient. In 
dementia praecox the appearance of expansive ideas follow- 
ing delusions of persecution indicates a decided progress 
of mental weakness. 

Disturbances of the Rapidity of Thought 

The normal rapidity of the association of ideas and con- 
cepts varies so greatly in different individuals, and some- 
times even in the same individual, that it has been 
impossible to establish a standard by which morbid devia- 
tions can be accurately estimated. We are, however, able 
to recognize two disturbances ; namely, retardation and 
acceleration of the train of thought. 

Retardation occurs even in healthy individuals as the 
result of physical and mental fatigue. Some unpleasant 
emotional states produce the same result. It also occurs 
during the intoxication produced by alcohol, ether, chloro- 
form, chloral, and to a moderate degree after the use of 
tobacco. This disturbance is characteristic of the depres- 
sive and mixed forms of manic-depressive insanity, is 


found in the end stages of dementia praecox and paresis, 
and in congenital imbecility. Moderate retardation ap- 
pears also in melancholia. 

Acceleration is less frequent than retardation. In nor- 
mal life it is produced only by some forms of emotional 
excitement, and by such drugs as morphine, caffeine and 
ethereal oil of tea. In morbid states genuine acceleration 
is probably never found. In flight of ideas the thought 
may appear accelerated, but even here real delay can usu- 
ally be demonstrated. 

Disturbances of Capacity for Mental Work 

The capacity for mental work is independent of the 
rapidity of thought. It is scarcely to be measured by 
direct experimentation, although it forms a most impor- 
tant symptom of mental disease. In normal life the capac- 
ity for mental work is determined by the residua of past 
efforts. These residua condition the increase of capacity, 
which we call practice. In morbid states the effects of 
practice are usually lessened and rapidly disappear, par- 
ticularly in congenital imbecility. 

The capacity for mental work stands in inverse ratio 
to susceptibility to fatigue. Increased susceptibility to 
fatigue is very general in most forms of insanity. We 
find it in exhaustion psychoses, dementia praecox, con- 
genital imbecility, and paresis, where it is often the first 
striking symptom of the disease. In neurasthenia it is 
often masked by increased nervous irritability. 

Recovery from fatigue is effected by relaxation and 
especially by sleep. Melancholiacs and neurastheniacs 
recover very slowly from the effects of mental, emotional, 
and physical activity. This is the result, in part of dis- 
eased mental tone, in part also it results from disturbances 


of sleep, not only in amount but depth. It has been shown 
that in conditions of simple overwork the sleep is light, 
attains its greatest depth very slowly, and shows an incom- 
plete abatement of its profoundness in the morning. 

Finally the capacity for work is markedly decreased by 
distractibility . It can arise from insufficient intensity of 
the goal ideas, from unusual vividness of individual pres- 
entations, or finally from an increased susceptibility to 
distracting influences. Inadequacy of the goal ideas is 
probably the cause of distractibility in paresis and dementia 
prsecox. The vividness of individual presentations is seen 
in the distractibility of acute exhaustion psychoses, and 
especially in manic-depressive insanity, and probably also 
in excited periods of dementia praecox and paresis. The 
increased susceptibility to distracting influences is a regu- 
lar symptom of neurasthenia, where quite insignificant 
forms of irritation may become altogether intolerable. 

Disturbances of Self-Consciousness 

The sum total of all those presentations which form the 
complex idea of our physical and mental personality con- 
stitutes self -consciousness. This is the permanent back- 
ground of our mental life, and exercises a great influence 
on the course of all our mental processes. In content as 
well as scope, self-consciousness is determined by the 
experiences of each individual. All morbid experience, 
therefore, must eventually disturb the apprehension of the 
individual personality and its relation to the external 
w T orld. Falsification of self-consciousness is, therefore, a 
very frequent disturbance. Its most important forms, 
however, have already been delineated in the discussion of 

In advanced deterioration self-consciousness ultimately 


falls into decay. In dementia praecox and paresis this is 
the usual terminus of the mental life. In some cases, on the 
other hand, even when the store of ideas is much impover- 
ished, the patient still retains his self-consciousness and 
can give an account of his own condition. This is partic- 
ularly common in epileptics. 


Every sensory impression which sustains any intimate 
relation to man's welfare is accentuated in consciousness 
by a concurrent feeling of pleasure or pain, depending on 
its apparent tendency to advance or retard the general 
aims of life. Therefore, the feelings are a direct indica- 
tion of the attitude of the ego to the perceptions of the 
external world. Disturbances of the emotional life often 
form the first striking symptom of disease. But the 
recognition and estimation of these disturbances is diffi- 
cult, because we lack an adequate normal standard. Even 
in health the emotions show marked personal peculiari- 
ties, closely allied to the abnormal. 

Diminution and Increase of Emotional Irritability 

The diminution of the intensity of the emotions is their 
simplest and most frequent disturbance. In normal life 
one's interest in the environment is reflected in more or 
less intense fluctuations of his emotions. Diminution of 
these emotional accentuations indicate indifference toward 
the impressions of the external world. This is character- 
istic of most forms of mental deterioration, of which it is 
one of the first and most striking symptoms. Emotional 
indifference may be marked even when external impres- 
sions are well apprehended and elaborated. This striking 
disproportion between disturbances of the intellect and 
the emotions is most pronounced in dementia praecox. 
In paresis, on the other hand, mental elaboration is dis- 
turbed to a much greater degree than the emotions. 



All phases of the emotional life seldom suffer equally. 
Naturally the patient loses most easily those feelings 
which are not directly connected with the changes of his 
own ego, but are related to the more remote, external 
world, and further those feelings which have lost their 
sensory properties and are aroused only through the higher 
mental processes as concomitants of general ideas and 
moral principles. The active interest of the patient 
becomes exclusively selfish. He loses all pleasure in 
mental work, and all feeling for the higher claims of pro- 
priety, morality, and religion. Consideration for his 
environment, his family, relatives, and finally for man- 
kind in general, has no influence on his conduct. He 
loses the sense of shame and lacks all comprehension of 
the conventions of social intercourse. 

This emotional deterioration is very often the first strik- 
ing symptom of dementia praecox, and advances with the 
progress of the disease. It regularly occurs in senile 
dementia, and sometimes is an early symptom of paresis. 
In its simplest form it appears, also, in simple senility. 
Emotional deterioration is also prominent in many forms 
of congenital imbecility, especially the so-called " moral 
imbecility," in which the patients show a certain shrewd- 
ness in the attainment of selfish advantages which often 
conceals the real severity of the disease. 

Lower or sensuous feelings possess a greater momentary 
intensity, but are at the same time more transitory than the 
higher moral aesthetic sentiments, which accompany and 
determine our thoughts and actions throughout our entire 
life, and act as checks on sudden emotional impulses of 
the lower order. 

The absence of these checks in imbecility gives rise to 
sudden, but transitory, outbursts of passion. Without a 


firm foundation for the emotional life a mere trifle, a 
word, the tone of the voice, suffices to plunge the patient 
from the most blissful self-complacency into the most pro- 
found despair. This is an especially prominent symptom 
in paresis. The emotional indifference characteristic of 
the end stages of dementia prsecox is regularly accom- 
panied by such emotional ebullitions. A permanent 
characteristic of emotional indifference is lack of insight. 
The retardation of depressed manic-depressive patients 
sometimes presents a superficial similarity to the emo- 
tional indifference of the deteriorated, but the former 
realize their condition, and often complain that they are 
forsaken and desolate. 

Increase of emotional irritability is characterized by fre- 
quent variations of mood. Every accidental impression 
has a lively emotional accentuation, giving rise to rapid 
emotional changes and sudden transitions from one mood 
to another. This change of "emotional tone" is an im- 
portant and characteristic symptom, especially in the 
excitement of the maniacal forms of manic-depressive 
insanity and in paretic excitement. As the train of 
thought leaps unsteadily from one subject to another, 
so the emotional attitude varies constantly in accordance 
with the ever changing impressions of the moment. In 
these conditions a definite fundamental emotional tone may 
prevail in the midst of the various rapid changes, giving 
way to opposing influences, only to recur just as abruptly 
in its former intensity. 

Lighter grades of morbid emotional activity are very 
often observed in some forms of congenital imbecility, in 
hysteria, and during convalescence from exhaustion psy- 
choses. These are characterized by frequent and abrupt 
alterations of mood, capriciousness, strong outbursts of 


feeling upon slight provocation, and a tendency to undue 
enthusiasm or gloom. 

Persistent Morbid Emotions 

In contrast to both the diminution and increase of emo- 
tional irritability, persistent morbid emotions are charac- 
terized by the persistent domination of some definite 
feelings over the emotional life. The feeling tone most 
frequently encountered here is sadness. A similar phe- 
nomena in the border-land of insanity is found in the 
normal life when temporary gloom seems to pervade 
experience. Persistent susceptibility to the unpleasant is 
often recognized as a congenital personal peculiarity in 
the constitutional psychopathic states. 

This increased susceptibility to the unpleasant is a pro- 
nounced but transient accompaniment of depression in 
various psychoses. The patient is unable to enjoy any- 
thing. All the natural pleasures of existence are trans- 
formed into a feeling of painful ennui. The unpleasant 
emotional state naturally induces "painful thoughts," 
fear, distrust, delusions of persecution, and self -accusation. 
The increased susceptibility to the unpleasant is sometimes 
associated with irritability, which finds vent in expressions 
of intense displeasure. Patients are usually fretful, dis- 
contented, at variance with themselves and their environ- 
ment; annoyed by every trifle, they grumble and growl 
in the most intolerable manner and show outbursts of pas- 
sion upon the slightest provocation. This occurs in the 
transition period between depression and excitement in 
manic-depressive insanity, also in convalescence from 
exhaustion psychoses and in melancholia. The passionate 
irritability of the epileptic and hysterical patients is of the 
same type. 



Fear is by far the most important persistent emotion 
encountered in morbid conditions. Even in normal indi- 
viduals it affects sympathetically the entire mental and 
physical condition, being accompanied by precordial op- 
pression, palpitation, paleness, increased respiration and 
tremor, and sometimes by perspiration and an increased 
tendency to urinate and defecate. In morbid conditions 
fear is usually without an object at first. The patients 
feel afraid without knowing why, and indeed are often 
well aware that their fears are groundless. In the con- 
stitutional psychopathic states the indefinite fear often as- 
sumes peculiar forms, as the feeling of homesickness, and 
the like. In acute mental disturbances the indefinite 
anxious forebodings become fixed into more or less defi- 
nite fears. Extreme fear, like all extreme emotions, is 
always accompanied by a clouding of consciousness. 

Fear is manifested by anxious excitement and by anxious 
tension. Anxious excitement is characterized by efforts 
at defence and escape, supplication for clemency, suicidal 
attempts, and assaults. Ketarded patients of manic-de- 
pressive insanity try to present to the threatening danger 
the fewest possible points of attack, crouch down, shut 
their eyes, and clinch their teeth. Anxious tension is not 
maintained at the same intensity for any considerable 
length of time, but shows remissions, especially at night. 
Fear is most pathognomonic of melancholia of involution, 
where it is seldom absent. It occurs frequently in de- 
pressive forms of manic-depressive insanity, but may be 
present also in the dreamy states of epilepsy, in delirium, 
and in the beginning of catatonic excitement. Paresis 
often presents the most extreme form of fear. 

Lighter grades of fear, in the form of permanent timid- 
ity and cowardice, are among the most frequent and char- 


acteristic symptoms of the constitutional psychopathic 
states. The patients from youth lack self-confidence, and 
are constantly in fear that they will do wrong. These 
congenital peculiarities form a favorable soil for the de- 
velopment of a further group of disturbances called com- 
pulsive fears, which include the fear at the sight of or 
contact with certain objects, as spiders, knives, needles, 
etc. ; also the fear of being alone on deserted streets, the 
fear of crowded rooms, of open or closed doors, etc. (see 
p. 383). These patients are tormented by the idea that 
their clothes do not fit properly, that they themselves are 
soiled or poisoned by contact with others, that they might 
have swallowed needles or fragments of glass, that in tear- 
ing up any scrap of paper they might have destroyed valu- 
able papers, etc. Other closely allied disturbances are the 
feelings of discomfort which arises whenever individuals 
are compelled to come into any sort of relations with 
others, as in erythrophobia, morbid blushing. 

The morbid feelings of pleasure are less frequent than 
those of displeasure. They occur especially in alcoholic 
intoxications and alcoholic psychoses, manic-depressive 
insanity, paresis, dementia prsecox, morphin and cocain 
intoxication. The feeling of increased strength, enthusi- 
asm, and enterprise which result from alcohol probably 
originate in the facilitation of the release of motor im- 
pulses in the brain, as further action of the drug causes 
irritability, restlessness, and aimless activity. In the 
maniacal forms of manic-depressive insanity in which 
there is a similar combination of pleasurable feelings, irri- 
tability, and pressure of activity, the emotional disturbance 
is believed to have a similar origin. This belief is sub- 
stantiated by physiological experimentation. In paresis 
the pleasurable feelings are apt to be marked, especially 


the feeling of well-being. In this disease, however, these 
feelings often exist unaccompanied by motor excitement, 
presenting a condition similar to that occurring in hasheesh 

In chronic alcoholism, as well as in delirium tremens, 
there is apt to appear a characteristic change of emotional 
attitude, called the drunkard's humor. Its origin is un- 
known, but may, however, arise from the drunkard's in- 
susceptibility to humiliation and his moral apathy to vice. 
In dementia praecox, during the excited stages, pleasur- 
able feelings take on the form of a silly, purposeless hilar- 
ity and exuberance, with outbursts of silly laughter, 
which, in contrast to the hilarity of the maniacal forms 
of manic-depressive insanity, seem to bear no relation to 
the patient's ideas and environment. 

Cocain, morphin, tobacco, and the bromides also produce 
characteristic feelings of well-being. In tobacco smoking 
the feeling of agreeable contemplation is due purely to a 
soporific effect; the bromides produce a feeling of well- 
being by relieving previous states of uncomfortable ex- 
citement. The feeling of ecstasy, which occurs especially 
in epilepsy, and sometimes in hysteria, seems to be very 
similar to the dreamy state which follows opium smoking. 
The origin of morbid feelings of pleasure is very difficult 
to determine, both because they may arise from a great 
many different disturbances, sometimes somatic and vaso- 
motor, sometimes primarily emotional and sometimes 

The optimistic emotional tone, which is a personal 
characteristic of some normal men, becomes really ab- 
normal in those fickle individuals who never look on 
serious matters seriously, who find everything "fine," 
and are always cherishing hopes of great things. These 


are characteristic of some forms of the constitutional psy- 
chopathic states. 

Disturbances of General Feelings. 

General feelings are those emotional states which stand 
in close and inviolable relation to self-preservation, such 
as feelings of fatigue and hunger. They are to be regarded 
as admonitions, which gradually develop out of the experi- 
ence of countless generations into involuntary and instinc- 
tive impulses. In ordinary life these feelings inform us 
of our bodily needs, and they imperiously exact actions 
adapted to the circumstances. The performances of these 
actions can usually be inhibited by conscious volition, al- 
though often only by means of great self-denial ; the feel- 
ings themselves are, on the contrary, only thoroughly 
silenced when the indicated need is relieved in some 
way or other. In normal life a general feeling may 
disappear when we pay no heed to it. We are able to 
overcome weariness when work demands our strength ; 
hunger abates when we are unable for a long time to 
satisfy it. When at last we have the opportunity to at- 
tend to our needs for rest and food, we miss at first the 
painful weariness and hunger which makes the restora- 
tion of our strength so easy. Only when we have rested for 
some time do we again experience a feeling of weariness, 
while hunger gradually returns as soon as we begin to 

In morbid conditions these general feelings may suffer 
profound disturbance. Fatigue may fail to indicate the 
actual need for rest. Especially in maniacal forms of manic- 
depressive insanity there is often a complete absence of 
weariness in spite of the fact that patients are exhausted 
by continual restlessness. Upon remission of the excite- 


ment, however, the weariness often comes over the patient 
in full force. The lack of weariness occurs in the excited 
states of paresis, in exhaustion psychoses, and in catatonia. 
In states of depression, on the other hand, the feeling of 
weariness is constantly present, although there is no real 
exhaustion, as the patient is unoccupied and possibly con- 
fined to bed. Both disturbances — weariness without 
exhaustion and exhaustion without weariness — are often 
associated in an odd manner in neurasthenia, and espe- 
cially in the constitutional psj^chopathic states. The 
patients, either permanently or at certain times, feel feeble 
without sufficient cause, unstrung and incapable of work 
but, on the other hand, they do not secure rest upon retir- 
ing at night, as the weariness preparatory to sleep will not 
come to them. 

The feeling of hanger is similarly disturbed in these 
same psychoses. In paretic and catatonic patients there 
is often a senseless voracity, although the well-nourished 
patients have no need of such an amount of nourishment. 
In the constitutional psychopathic states and in hysteria, 
without any perceptible relation to the state of bodily 
nutrition, there may be a prolonged absence of the feeling 
of hunger, which is suddenly replaced by gluttony. 

Severe disturbances of the feeling of nausea are almost 
always signs of a far-advanced deterioration. Such 
patients consume the most disgusting things, even their 
own dejections. Not infrequently they swallow nails, 
stones, pieces of glass, or animals, not only with suicidal 
intent, but constantly overpowering their nausea from 
pure greediness. These patients also lose those feelings 
which cause us aversion at the mere contact with filth or 
dirt and impel us to keep clean, not only our bodies, but 
our whole environment. They recklessly soil themselves, 


even intentionally, with their own food, their own saliva, 
urine, and even feces. 

The feelings of physical pain are often abolished. In 
conditions of excitement, especially with intense fear, even 
severe injuries produce no sensation at all, although con- 
sciousness may be perfectly clear. Such patients pluck 
out their tongues or eyes, cut open the abdomen, etc., deeds 
which would be utterly impossible for a man with a normal 
sense of pain. This insensibility to physical pain is often 
found in demented patients, especially in paretics, in whom, 
to be sure, the destruction of the nervous conducting paths 
is an essential antecedent. 

The sexual feelings, which pertain to the maintenance 
of the race rather than to self-preservation, may be 
increased, abolished, or perverted in disease. Sexual 
indifference occurs in many forms of the constitutional 
psychopathic states, and particularly in hysteria, also in 
morphinism. An increase of sexual excitability is found 
in some idiots, but in a more pronounced degree in dementia 
praecox, and also in the excited stages of paresis and the 
maniacal forms of manic-depressive insanity. Perverted 
sexual feelings are those in which sexual feelings occur 
exclusively in connection with persons of the same sex, 
associations with certain objects, or accompanied by 


All disturbances of the psychic life find their final 
expression in volition and action. The idea of a definite 
aim (some change either in ourselves or our environment) 
forms the starting-point of a volitional act. This idea is 
accompanied by feelings which are converted into impulses 
for the attainment of that aim. The direction of any 
action is determined, therefore, by an idea, while its per- 
formance is determined by the intensity and the duration 
of the accompanying feelings. 

Morbid disturbances of volition manifest themselves in 
the most varied ways : (1) the energy of the volitional 
impulse can be diminished or increased; (2) its release 
facilitated or impeded ; (3) or the direction can be modi- 
fied by external or internal influences ; (4) morbid impulses 
can forcibly suppress the normal will ; (5) or natural 
impulses can assume morbid forms ; (6) finally, the con- 
duct of the insane is naturally influenced by all those dis- 
turbances which occur in other spheres of their mental 
life, although the volitional process itself presents no 

Diminution of Volitional Impulses 

The complete suspension of volitional activity is termed 
paralysis of the will. It is produced by extreme fatigue, 
profound alcoholic intoxication, and in the narcoses of 
chloroform, chloral, and morphin. It is characterized 
by an absence of energy. Ordinary impulses find no 



issue in action, while even the most powerful incentives 
of personal well-being and moral claims fail to influence 
the patient. A more or less complete paralysis of the 
will occurs in the end stages of progressive mental deteri- 
oration : senile dementia, dementia praecox, and paresis. 
This is characterized by a marked diminution of personal 
initiative, except in gratification of the lower, selfish, and 
vegetative impulses, such as greed, gluttony, and sexual 
desire. If left to themselves, the patients are content to 
sit around, inactive, displaying very little animation and 
staring vacantly into space. In dementia praecox it can 
often be shown that the patients have not lost the volun- 
tary control of their actions, but normal incentives fail to 
influence them. In the end stages of deterioration the 
only movements are involuntary and reflex. Similarly, 
defective volition appears in congenital imbecility as the 
result of defective development. 

Increase of Volitional Impulse 

The universal indication of the increase of volitional 
impulse is motor excitement. But we are really justified in 
speaking of an increase of volitional impulse only when 
there is a marked disproportion between the intensity of 
the excitation and the importance of the motives. In 
alcoholic delirium, for example, we find marked unrest 
which cannot be explained by the patient's delusions, hal- 
lucinations, or emotions, but must be referred to a morbid 
motor excitation. Patients will not remain in bed, show 
a pronounced restlessness, and constantly busy themselves 
as if employed in some occupation. In alcoholic intoxi- 
cation increase of volitional impulses begins with simple 
loquacity, and increases to brawling, screaming, and aim- 
less activity. In chronic cocain intoxication (see p. 140) 


there develops a peculiar motor excitability which seems 
to form a transition to the morbid pressure of activity which 
is a characteristic symptom of manic-depressive insanity 
(see p. 288) and is sometimes found in exhaustion psy- 
choses and paresis. 

In the lighter hypomaniacal disturbances this pressure 
of activity takes the form of general instability and busi- 
ness, great talkativeness, and a tendency to animated ges- 
ticulation. Such patients collect all sorts of useless things, 
begin countless undertakings which they never finish, and, 
when unrestrained, travel aimlessly about. In more 
marked excitement the goal ideas become more and more 
inconstant, and one can hardly detect any purpose at all 
in their ever changing, incoherent activity. Patients 
scream, laugh, sing, dance, disrobe, tear their clothing, 
smear themselves, wash in their own urine, destroy every- 
thing they can reach, and pound incessantly with their 
hands and feet. 

Catatonic excitement furnishes a picture essentially dif- 
ferent from that of the maniacal pressure of activity. In 
the maniacal excitement, all impulses lead to more or less 
purposeful actions, though they might at first appear pur- 
poseless and senseless. In catatonia, on the contrary, we 
have to do with movements which at most have no defi- 
nite aim. The name "pressure of activity," which has 
formerly been used for the maniacal stress of action, would 
really be more applicable to this condition. Although the 
characteristic excitement in catatonics is often more mod- 
erate, the movements are entirely purposeless. Such 
patients make grimaces, contort the body, run about, clap 
their hands, and utter a succession of senseless noises. 
These movements are not pure volitional acts, as there is 
no antecedent idea of their purpose. Patients themselves 


often assure us that they do not know why they perform 
such absurd antics. 

dlstubbances in the release of the volitional 


The strength and rapidity with which a volitional im- 
pulse is converted into action is dependent, not only on its 
own intensity, but also on the resistance which it has to 
overcome. Thus, fright and fear may present obstacles 
to the realization of our intention, which can be overcome 
only by the most strenuous exertion of the will. 

The psychomotor retardation, which is the most impor- 
tant disturbance in the depressed states of manic-depressive 
insanity, is probably due to a similar increase of resistance. 
Such patients require special exertion of the will for almost 
every movement. All the actions are characteristically 
slow and weak, except when a powerful emotional shock 
breaks through the resistance. In severe cases indepen- 
dent volitional action is almost impossible. In spite of 
every apparent exertion, the patients cannot utter a word, 
and are unable to eat, stand up, or dress. As a rule they 
clearly recognize the enormous pressure lying upon them, 
and which they are unable to overcome. The name 
" stupor " is usually applied to these disturbances, but they 
are only superficially related to the stupor of catatonia. 

In catatonic stupor the release of movements in itself is 
not rendered difficult, as action is occasionally both rapid 
and powerful. But every impulse is almost immediately 
followed by the release of an opposing impulse which pre- 
vents the consummation of the act. Thus, we often see 
the desired movement begin all right, but it is immediately 
interrupted and extinguished by the opposing impulse. 
Here the impulse is not hindered by internal resistance, 


but is simply quenched by a counter impulse. In contrast 
to the retardation, in which there is a continuous hindrance, 
one might refer to this as an " embargo/ ' As soon as the 
embargo is raised, the counter order disappears, and the 
action goes on without the slightest difficulty. 

The facilitated release of volitional impulses is a general 
characteristic of childhood and the female sex. In hys- 
teria it takes the form of permanent, increased excitability. 
The most diverse impulses give rise to action, not so much 
on account of their intensity, as because of the lack of the 
normal restraining influences. In alcoholic intoxication, 
on the other hand, there is an added motor excitement, 
which is independent of external stimuli. In maniacal, 
catatonic, and some paretic patients, besides the facilitated 
release of impulses there is an increase in the intensity of 
the movements. On the other hand, in some retarded 
states in manic-depressive insanity, there can develop an 
increase of psychomotor irritability without any signs of 
actual excitement. 

Heightened Susceptibility of the Will 

The motives of action have two sources : (1) external 
stimuli; and (2) those relatively constant principles of 
action which arise from within rather than from without, 
and render the individual's conduct more or less indepen- 
dent of his surroundings. The control of actions by these 
general principles is lacking only in children and unstable 
individuals. In diseases this control is lost in weakness 
of the will, increased psychomotor excitability, and in con- 
flict with overwhelming morbid impulses. 

Weakness of will is found in all forms of imbecility, 
where the fixed principles of action are lacking. There is 
no internal unity or consistency in conduct. The chief char- 


acteristic is a hypersuggestibility, through which the pa- 
tients become the prey to every accidental influence. This 
condition is found in its purest form in paresis. Similar 
phenomena are induced through suspension of these fixed 
principles of action by means of hypnotism. 

Transient hypersuggestibility is found in catalepsy, 
where often the limbs of the patient will remain in any 
position in which they are placed until, as the result of 
extreme muscular exhaustion, they tremblingly obey the 
laws of gravity. In this condition there is often found a 
moderate, but constant, muscular resistance called " cerea 
flexibilitas," in which it is possible to mould the limbs 
into any desired position. Less often patients are found 
who will repeat for some time any simple movement, once 
started, or who will laboriously imitate everything done 
in their presence (echopraxia). In echolalia the patient 
involuntarily repeats every word he hears, although at 
the same time giving evidence of considerable elaboration 
of impressions by his ability to solve simple problems. 
Indications of these symptoms, especially cerea flexibilitas, 
are occasionally observed in the most varied diseases, such 
as hysteria, epilepsy, maniacal forms of manic-depressive 
insanity, paresis, and alcoholism ; but the whole group of 
symptoms is most pronounced in dementia praecox, espe- 
cially the catatonic form. 

Distractibility of the will is a morbidly easy translation of 
ideas into action. It usually accompanies heightened sus- 
ceptibility of the will, but is differentiated from it by a 
reaction to internal as well as to external stimuli. It is 
to conduct what the distractibility of the attention is to 
intellection, and effectually prevents all permanent voli- 
tional control of action. Sudden resolutions are half 
carried out only to yield to new ones. The patients are 


wholly under the influence of the environment, whether 
good or bad. Distractibility of the will is found in cer- 
tain conditions of maniacal and delirious excitement. It 
accompanies hysteria and some forms of imbecility as a 
permanent personal characteristic. 

The distractibility of the will may not be equal in all 
directions, but only in certain specific directions. This 
is especially characteristic of the catatonic form of demen- 
tia praecox. The embargo of the will, described above, is 
probably an example of this, in which the impulse at the 
very onset is deflected into an opposite direction. Another 
disturbance is the crossing of impulses, where acts are 
completed very differently from the way in which they are 
begun. For instance, the catatonic may push persistently 
against a locked door toward which he had started, when 
he could easily leave the room through an open door by a 
little detour. 

In stereotypy also there is a morbid persistence of a voli- 
tional impulse once started. It is manifested by (1) con- 
tinued tension of definite groups of muscles, and (2) by 
numerous repetitions of the same movements. 

(1) These patients remain in the same place and atti- 
tude for an almost incredible length of time in spite of the 
greatest discomfort. They stand in the same corner, kneel 
in a definite place, lie in bed with legs curled up and head 
extended, so rigid that they can be lifted like a log. 
Others grip a piece of bedspread with their teeth, or con- 
vulsively grasp a piece of bread or torn-off button. The 
expression of the countenance is also rigid, mask-like, the 
forehead drawn up as if in surprise, the eyebrows elevated, 
and the eyes often wide open. The eyeballs are often 
turned sidewise and the lips are protruded until they look 
like a snout. 


(2) Stereotyped movements have an unlimited variety. 
The patients turn somersaults, rap rhythmically, walk 
about in peculiar places, hop, jump up and down, roll and 
creep on the ground, pick at the clothing or hair, and grit 
the teeth. These movements can be repeated innumerable 
times, for weeks or even months. In all these movements 
the patients are absolutely reckless of themselves and their 
environment. Mannerisms are a kind of stereotyped 
movement, consisting of ordinary movements peculiarly 
modified. The patients walk with a peculiar gait, drag 
one foot, go in straight lines or in circles, hold the spoons 
at the very end, eat in a definite rhythm, and shake hands 
with stifHy extended fingers. Mannerisms are especially 
common in speech. Grunts, lisping, peculiar words, 
phrases and inflection, and numerous repetitions of the 
same words are among the most frequent forms. Stereo- 
typy is a characteristic of the catatonic forms of demen- 
tia praecox, but also occurs in exhaustion psychoses and 
in paresis, where it is only a transient symptom. 

Diminished Susceptibility of the Will 

Increased susceptibility of the will in one direction is 
sometimes accompanied by a diminished susceptibility in 
another. Thus, in stereotypy the senseless repetition 
naturally prevents a normal reaction to the environment. 
This condition is also the basis for negativism, a frequent 
accompaniment of stereotypy. 

Negativism consists in the reaction to stimuli which 
are the reverse of the normal reaction. Patients do just 
the opposite from that which they are requested to do : 
press their teeth together when asked to show their tongue, 
close the eyes when an attempt is made to examine their 
pupils, and refuse to answer questions (mutism), although 


they sometimes speak spontaneously. They offer the most 
powerful, but almost always passive, resistance to every 
external encroachment : will not allow any one to dress 
or undress them, will not bathe or take care of themselves, 
and offer strenuous resistance to compulsory feeding, but 
when unmolested eat greedily. The feces are often re- 
tained with the greatest exertion, especially if the patients 
are taken to the closet. As soon as they are returned to 
bed, the evacuation immediately takes place. 

Negativism is not due to voluntary opposition. Pa- 
tients sometimes admit after the attack that they do not 
know why they acted as they did. Negativism, stereo- 
typy, and loss of will probably all have the same basis. 
They often occur in the same patient, and may be easily 
made to pass into one another. They are most frequent 
in catatonia, and are sometimes found in a less pronounced 
form in paresis, senile dementia, and idiocy. 

Catatonic negativism must not be confused with the 
conscious resistance of terrified patients. In catatonia 
there is no conscious reason for resistance, and no persua- 
sion can overcome it. It is not influenced by pain, and 
the manner of resistance is always constrained and often 
absurdly inappropriate. The stubbornness of imbecility, 
epilepsy, hysteria, paresis, and senile dementia is closely 
allied to negativism, but in contrast to negativism it 
always starts with an idea, and is more or less influenced 
by persuasion, new ideas, and emotional changes. More- 
over, in stubbornness the general emotional attitude is 
fretful, irritable, and unruly. The patient shows fight, 
and is often dominated by confused, malevolent delusions, 
whereas the negativistic patient shows great equanimity, 
he seldom defends himself, and almost never attacks, but 
merely resists. 


Compulsive Acts 

Compulsive acts are those which do not arise from nor- 
mal antecedent consciousness of motive and desire, hut 
seem to the patient to he forced upon him hy a will which 
is not his own. As a rule, the patients struggle against 
the morbid impulses ; often caution those about them at 
their approach, and adopt measures to prevent harm to 
others. The accomplishment of the act is accompanied 
by a feeling of relief, and is usually followed by clear 
insight into the nature of the act, accompanied by chagrin 
and remorse. 

Compulsory acts are generally accompanied by great 
emotional excitement, and stand in close relation to com- 
pulsory ideas and fears already described (see p. 51). 
These disturbances all originate on a basis of congenital 
morbid endowment, and are all a part of the symptoms of 
the constitutional psychopathic states. 

Impulsive Acts 

Impulsive acts are distinguished from compulsory acts, 
in that they do not seem to the patient to he influenced 
from without, hut are the direct expression of a sudden 
overwhelming impulse, which gives no chance for reflec- 
tion or resistance. 

They are found in the most varied morbid conditions. 
Probably the pressure of activity in maniacal forms of 
manic-depressive insanity is of this type. Here belong 
also the wanderings and assaults of the epileptic (see pp. 
342, 343), the excesses of the dipsomaniac, as well as 
the morbid impulses of hysteria, self-inflicted injury, theft, 
and fraud. Their origin does not lie in definite feelings 
of pleasure or dislike, but in marked motor excitement. 


The patient's consciousness is dominated by one blind 
impulse without clear motive or realization of the out- 
come. The execution is rapid and reckless, and the 
patients are correspondingly dangerous. 

Morbid Impulses 

A disturbance of the natural impulses is a symptom of 
all general morbid changes of volitional action. In pa- 
ralysis and inhibition of psychic processes all the appetites 
are diminished ; in excitement, on the other hand, appe- 
tites are increased, especially sexual desires. The latter 
seldom lead to actual assault, but manifest themselves in 
ambiguous phrases, abusive language, and by more or less 
reckless masturbation : in women, by shameless exposures, 
extreme uncleanliness, or incessant washing with water, 
saliva, or urine, combing and unloosing the hair ; in 
lighter forms, by adornment and flirtation, by an alterna- 
tion between seductive, shamefaced, and sentimental man- 
ners, by hand pressing, letter writing, significant glances, 
and the like. Less frequently in maniacal excitement 
there is found an increased desire for food; although 
restlessness usually hinders the patients from taking 
sufficient nourishment. On the other hand, excessive 
greediness is not infrequently found in idiots, paretics, 
and especially in catatonics. Incredible quantities of the 
most unpalatable and disgusting things, sand, stones, sea- 
weed, feces, etc., are sometimes devoured by such patients. 
In these last cases there is not a simple increase of healthy 
impulses, but probably a simultaneous perversion of the 
appetite both in nature and direction. The same is true 
of the well-known excessive desire for eating suddenly 
manifested by pregnant women. Much more numerous, 
however, are the morbid sexual impulses, which in recent 


years have been most thoroughly investigated. The most 
pronounced of these are the contrary sexual instincts, in 
which the sexual feelings and desires are exclusively 
directed toward members of the patient's own sex. 

Sadism consists in the attempt to increase or induce 
sexual excitement by brutality. In the final stage of its 
development actual sexual congress is a matter of indiffer- 
ence. In masochism, on the other hand, the endurance 
of pain increases sexual excitation or may be substituted 
for it. The satisfaction of sadism appears to arise from 
the feeling of absolute power over the victim, while that of 
masochism arises from the most complete subjection to the 
will of another. In fetichism particular articles of cloth- 
ing or parts of the body become either the necessary 
adjuncts for satisfactory coitus, or the simple observation 
or contact with the fetich may satisfy the sexual impulse. 
The most common fetiches are boots, shoes, handkerchiefs, 
underclothing, and finally velvet and furs. 

Besides the perversion of normal impulses as seen in 
the above, there is a group of morbid impulses which 
seem to bear no relation to normal life. Such are klepto- 
mania, the irresistible impulse to steal all manner of worth- 
less and useless things ; pyromania, the impulse to burn. 
Both these usually arise on the basis of an epileptic or 
hysterical endowment. 

The whole series of abnormal impulses are partial symp- 
toms of a general morbid endowment, and indicate con- 
genital degeneracy. It is possible that kleptomania and 
pyromania should be regarded as compulsive acts. The 
impulse appears as an obtrusive compulsion which is re- 
sisted as long as possible, while the performance of the 
act is accompanied by a feeling of relief. 


Disturbances of Expression 

The movements by which patients express their ideas, 
feelings, and impulses are among the most important clews 
to morbid psychic impulses. A full delineation of the 
symptoms of the various disease types occurs in the clini- 
cal portion of this work. In this place we confine our- 
selves to a few characteristic indications. 

Dementia praecox is indicated by lack of interest, not- 
withstanding accurate apprehension, by listlessness, strained 
attitudes, senseless grinning or laughter, with sudden im- 
petuous movements. Paretics may often be recognized 
by their awkward friendliness and production of silly ex- 
pansive ideas. Depressed patients sit around collapsed 
and flaccid, with troubled expression. Their movements 
are slow and laborious. The apprehensive patients are 
restless, bite their nails and wring their hands. In extreme 
retardation, they lie motionless in bed with fixed expres- 
sion and whisper their answers with great exertion. The 
manic-depressive, on the contrary, moves rapidly about, 
talks, cries, sings, plays tricks on his fellows, and busies 
himself with all sorts of things. The hysterical patients 
arrange their clothing and hair to make an impression. 
The paranoiac endures his hospital confinement with 
dignity, carrying with him the documents which prove all 
his pretensions. 

Alterations of speech and writing are of the greatest 
diagnostic value. Delusions are usually betrayed by the 
content of the communications. In maniacal patients 
there is incessant babbling, with a tendency to puns and 
rhymes. This is also found in excited paretics with more 
or less disturbance of articulation. In both diseases speech 
may be reduced to an incomprehensible gibberish, though 
from different causes. 


In retarded patients speech is low and difficult. Mel- 
ancholiacs express their thoughts laconically, and often 
keep up a monotonous lamentation. Catatonics are often 
mute for weeks at a time, and then suddenly begin to speak 
fluently or sing, although more or less confusion of speech 
is always present. Their stereotypy is manifested by con- 
stant repetition of the same words, phrases, or even sense- 
less syllables, while they frequently make up entirely new 

Disturbances of writing correspond both in content and 
form with those of speech. The manic-depressive patient 
fills sheet after sheet of paper with large, showy, and 
hastily written characters, which are often illegible even 
to the writer. The paretic's writing shows omission, mis- 
placement of words and syllables, blots, untidy corrections, 
and uncertainty. Hysterical patients use innumerable 
marks for emphasis. In melancholiacs the individual 
characters are incomplete, small, and crowded. The same 
is true in retardation. Catatonic patients cover the paper 
with unintelligible scrawls, endlessly repeated (written 

Conduct arising from a Morbid Basis 

Since conduct is the expression of the entire psychic 
life, we readily understand why it is more or less seriously 
disturbed by morbid changes in any part of the psychic 
individual, while, on the other hand, no isolated act can 
be taken as an infallible index of the exact morbid condi- 
tion. Delusions of sinfulness impel patients to penance, 
self -mutilation, or suicide. Delusions of persecution lead 
to mysterious precautions, to misanthropic isolation, to 
restless wandering, or even to outbursts of rage and mur- 
derous attacks against supposed enemies. Hypochrondria- 


cal delusions may lead to revolting smearing, self -mutilation, 
or injurious and absurd curative attempts, often with the 
evident purpose of attracting attention and sympathy. 

Mental excitement very soon leads to conflicts with the 
environment, to breaches of the public order, and quite 
often to resistance to civic authority. Patients behave in 
a reckless and striking manner. They are ungovernable, 
irritable, and violent under contradiction and restraint. 
At first they act as if intoxicated, and later become still 
more restless and even dangerous. There is usually also 
a tendency to sexual excesses, in which they indulge with- 
out regard to decency or morality. Such excited states 
are regularly accompanied by all sorts of mad pranks, 
destruction of property, adventurous journeys, brawls, and 
public scandals. When associated with expansive ideas, 
the patients purchase large amounts of useless stuff, pre- 
pare for mythical undertakings, and spend large sums of 
money. The idea that everything in their neighborhood 
belongs to them induces the patients to innocently appro- 
priate whatever they happen on, to embezzlement or to 

Paranoiacs systematically prepare their claims, address 
letters to prominent officials, and publish pamphlets. In 
their attempts to compel notice they appear on the street 
in unusual costumes, attack prominent persons, and create 
public scandals. Love-letters, proposals, etc., are directed 
at the supposed secret lover. The religious paranoiac 
founds a church and seeks a martyr's crown. 




The mental disturbances here described are supposed 
to develop primarily from toxins of infectious diseases. 

They are fever delirium, infection delirium, and psy- 
choses characteristic of the post-febrile period. 

Fever delirium follows rather closely the clinical course 
of the fever, and in a measure depends upon it. The 
infection delirium corresponds to the initial deliria of 
other authors, appearing at, or near, the onset of infec- 
tious diseases, independently of fever. The remaining 
group includes the various forms of mental disturbance 
which follow the infectious disease, developing during or 
following the fever, and are apt to lead to permanent 
mental enfeeblement. Other writers describe these under 
the various diseases which they accompany; as, typhoid 
delirium, pneumonic delirium, influenza insanity, and 
insanities following exanthemata. The mental symptoms 
arising from the toxins of the different infectious diseases 
cannot as yet be sufficiently differentiated to permit of 
their being considered as characteristic of the correspond- 
ing disease. The only distinguishing features are the 
physical symptoms characteristic of the different diseases. 
It is still a question whether the changes in the cortical 
neurones are due directly to the toxins produced by the 



micro-organism, or to an autotoxin developing within the 
body as a result of the infectious disease. 

A. Fever Delirium 

The clinical picture of fever delirium presents different 
grades corresponding to the intensity of the toxic action 
upon the cortical neurones, varying from moderate irrita- 
tion to paralysis and finally to complete destruction. 

Etiology. — The form of febrile disease has very little 
influence on the type of delirium, which apparently is 
modified only by the rapidity of the development of the 
fever, its intensity, and duration. Besides the toxin pro- 
duced in the febrile disease, the rise in temperature, accel- 
eration of metabolism, and disturbance of circulation 
should be regarded as causative factors. In addition there 
should be included alcohol, which plays such an important 
part in pneumonia, and the individual powers of resistance, 
as it is well known that children, women, and nervous 
men show a tendency to develop delirium with any severe 
form of fever. 

Symptomatology. — In the lightest grade of fever delir- 
ium there is irritability, some restlessness, general hyper- 
esthesia, insomnia with anxious dreams, a feeling of numb- 
ness in the head, and a desire to be left alone. 

In the next grade there is a marked clouding of con- 
sciousness ; illusions and hallucinations largely dominate 
ideation, rendering the association of ideas dreamy. The 
designs on the carpet and ceiling appear as moving forms 
or grinning faces, the bedpost assumes the form of an 
angel. Frightful outcries or beautiful music are heard, 
patients have airy floating sensations, and are led about 
through gorgeously decorated rooms. These dreamy 
experiences are interrupted momentarily by a return to 


normal consciousness. The emotional attitude becomes 
either much exalted or depressed. The activity increases 

In the third grade the disturbance of consciousness 
becomes very pronounced, ideation is completely incohe- 
rent and irrelevant. There are many varied emotional 
outbreaks and frequent wild impulsive movements, which 
soon become irregular and uncertain, indicating the onset 
of paralysis. The great restlessness is interrupted by 
short periods of sleep. 

In the fourth grade the movements become absolutely 
purposeless. At this time carphologia appears with sub- 
sultus tendinum. The utterances become indistinct, and 
consist in mumbling over incoherent words and sentences. 
From this the patient may enter into a state of coma vigil, 
when, in spite of open eyes, he is oblivious to all his sur- 
roundings and unable to indicate his desires. The urine 
and feces are passed involuntarily. 

Course. — The duration of the psychosis in three-fourths 
of the cases does not extend beyond one week, the delirium 
usually subsiding with the temperature. Some of the 
delusional ideas held during the disease may be retained 
for a long time. One patient during the delirium attend- 
ing pneumonia believed that his brother had misconducted 
the business and appropriated funds for his private use, 
which idea he held for several months after complete 

The prognosis is naturally poor because of the severity 
of the initial disease. If the delirium advances to the 
third or fourth degree, at least one-third of the cases die. 
Where there is hyperpyrexia the prognosis is extremely 
doubtful. A few cases emerge from the fever delirium 
into an exhaustion psychosis, or may end in dementia. 


Finally, the delirium may be the starting-point of other 
psychoses, as manic-depressive insanity, dementia praecox, 
or dementia paralytica. 

Besides the treatment of the initial disease, the ice cap 
should be applied to relieve cerebral hyperemia. Cold 
baths or cold packs -with friction are most serviceable. 
In case of cardiac weakness one must be cautious in the 
use of the bath, and if necessary administer a cardiac 
stimulant. For this purpose strong coffee is very valu- 
able. Antipyretics in this condition are not only use- 
less, but often aid in producing the delirium. One of 
the most important indications is constant attendance, 
both to prevent harm to others and injury of the patient 
by escaping out of doors or jumping out of windows. 
Where there is very great excitement, it is usual in 
general hospitals to make use of restraint sheets or 
canvas jackets. The same result is accomplished in the 
insane hospitals through the assistance of a restful and 
clever nurse, together with the bed treatment and pro- 
longed baths (see p. 89). If impulsive movements are 
a prominent feature, it may be necessary to improvise 
padded beds with high sides, or to resort to padded 
rooms. The use of hypnotics and narcotics is distinctly 

Infection Delirium 

In this group of psychoses are classified mental disturb- 
ances believed to arise from the specific toxins of hydro- 
phobia, typhoid, smallpox and malaria, because they 
appear independently of temperature. 

Pathological Anatomy. — Nissl has reported one case in 
which there was distention of the vessels of the cortex, 
with increase of white blood corpuscles and pronounced 


degenerative changes in the nerve cells. The cell bodies 
were swollen, the chromophiles were dissolved, and the 
processes diffusely stained for some distance. Karyoki- 
nesis was observed in nuclei of the glia cells. These 
changes, which are similar to those produced by experi- 
mental intoxication, tend to prove that we have to do 
with a psychosis depending upon intoxication. 

Symptomatology. — In the initial delirium of typhoid, 
which develops at the beginning of the disease, there 
are, according to Aschaffenburg, 1 two distinct forms. The 
delirium of one is quiet and accompanied by pronounced 
delusions and hallucinations. The patients believe them- 
selves poisoned and persecuted in various ways, are 
damned and cursed, distant relatives are heard talking 
to them, they see fire and threatening forms. Some- 
times they relate frightful and adventurous experiences. 
In emotional attitude they are sad and anxious. 

The other form of delirium, which may develop directly 
from the first, bears the signs of intense excitement. There 
develop very rapidly delirious confusion with flight of ideas, 
hallucinations, incoherent delusions, marked anxiety, and 
silly, impulsive movements. 

This second form is characteristic also of mental disturb- 
ance, appearing at the onset of smallpox and replacing 
the fever in malaria. In malaria the mental disturb- 
ance is intermittent, often entirely replacing the rise 
of temperature, and sometimes the other charac- 
teristic symptoms. It occurs most frequently with 
the quartan, and seldom with the tertian or quotidian 
forms. Since the general use of quinine, this mental 
condition is rarely encountered. 

In smallpox, during the formation of pustules, between 

1 Aschaffenburg, Allg. Zeitschr. f . Psy. LII. 


the eruption and pus fever, there is a characteristic mental 
disturbance, which, it seems, must be due to intoxication. 
Clear hallucinations of sight and hearing suddenly appear, 
while the patients remain perfectly conscious ; in fact, they 
are only annoyed by the sensory disturbances. They see 
persons walking around the room, blossoms flying about 
in the air, hear music, curses, indictments for theft or 
arson and are sought by the police. 

Besides the psychical disturbances in these infection 
psychoses, there are present the various physical signs 
characteristic of the initial diseases; the convulsive 
movements of hydrophobia, the weakness and headache 
of typhoid, the prodromal eruption of smallpox, and the 
enlargement of the spleen in malaria. Sometimes there 
appear epileptiform convulsions, hemiparesis, and disturb- 
ances of speech. 

The course is varied. In hydrophobia there may be 
clear intermissions. In the initial delirium there is 
often a remission during the day in which the patients 
remain somewhat stupid and disoriented. The duration 
is rarely longer than a week. 

The prognosis varies. In hydrophobia the delirium ends 
in a fatal collapse. In typhoid the condition may clear up 
with a marked fall of temperature, or it may pass over into 
a characteristic fever delirium. Only forty to fifty per cent, 
recover. The prognosis in malaria is favorable. 

The treatment in a great measure can be only sympto- 
matic. Some believe that they have secured beneficial 
results from a thorough flushing of the body combined 
with salt infusion. In malaria the mental disturbance 
responds immediately to quinine. 


Psychoses Characteristic op the Post-febrile Period 

of Infectious Diseases 

The onset of these conditions usually occurs before the 
subsidence of the fever. In some cases, however, they do 
not appear until after the disappearance of the fever, 
bearing the same relation to the infectious disease as do 
neuritic sequelae; as, for example, paralysis following 
diphtheria. Not all psychoses following the infectious dis- 
eases belong to this group, as dementia prsecox or attacks 
of manic-depressive insanity may appear at this time. 

Symptomatology. — The mental disturbances show in 
common a more prolonged course and a tendency to 
mental deterioration. 

The lightest form of psychosis is represented by those 
cases of mental and physical weakness which appear dur- 
ing convalescence from severe attacks of infectious dis- 
eases. After the subsidence of the fever, the patients fail 
to show their former energy. They are dull and heavy, 
constrained, and are very susceptible to fatigue. They 
cannot collect their thoughts, and find it difficult to read 
and write. They are indifferent, idly lie abed, and do 
not exert themselves to even concentrate their attention 
upon what is being read or spoken to them. There is no 
disturbance of consciousness or apprehension. There may 
be transient hallucinations, when for a few moments they 
hear unintelligible sounds, see faint visions, or experience 
peculiar bodily sensations. In emotional attitude they 
are rather sad and melancholic, sometimes irritable, oc- 
casionally anxious, especially at night. They may at 
times exhibit a distrust of their surroundings, transi- 
tory fear of poisoning, hypochondriacal ideas, and even 
delusions of persecution, the latter associated with aggres- 


sive attacks and attempts at suicide. In actions they are 
inclined to be reserved, silent, and reticent about their 
delusions. Physically, sleep and appetite are much dis- 

This condition most frequently follows pneumonia and 
rheumatism, and sometimes diphtheria. The duration 
varies from weeks to months. 

In the second group the following symptoms appear in 
the course of the fever : marked clouding of consciousness, 
numerous delusions and hallucinations, and anxious rest- 
lessness. The patients become completely disoriented, do 
not recognize their friends, claim that God or the Virgin 
Mary appears to them, that the bed moves, they are lying 
in a morgue with corpses about them, faces peer in at the 
open window, some one is after them, they are dismem- 
bered and about to die. Their speech is confused and 
incoherent. The confusion continues even after the 
temperature has subsided and the symptoms of the initial 
disease have disappeared. Gradually the patients become 
clearer and more composed, but the hallucinations and 
delusions persist. They still hear threatening voices, see 
grinning faces looking in at the window, and must get 
out of the bed and at them. Some one pulls the bedding, 
the food is not genuine, they are poisoned, no one is will- 
ing to do the right thing for them. In manner and ac- 
tions they are obstinate, resistive, refusing nourishment, 
grumbling, anxious, and even yield to emotional out- 
breaks and suicidal attempts. They lose weight rapidly, 
sleep poorly, and are restless. 

As the appetite and sleep improve, the hallucinations 
and delusions disappear. They gain insight into their 
condition, begin to busy themselves, and resume their 
accustomed manner and conduct. A certain unusual sus- 


ceptibility to fatigue, and absence of the wonted mental 
and physical energy, together with weakness of memory, 
persist for some time. A few cases never completely re- 
cover. A fatal termination is rare, and always due to 
some complication. The duration varies from several 
months to a year. This form follows especially typhoid, 
smallpox, articular rheumatism, and cholera. 

In adults there may be some difficulty in differentiating 
this condition from melancholia of involution. It is 
to be distinguished by the history of the infectious 
disease, the greater prominence of hallucinations, the pre- 
dominance of delusions of persecution over self-accusa- 
tions, and the great irritability in contrast to the anxiety 
of the melancholiac. It is to be differentiated from de- 
mentia precox by the great disturbance of apprehension 
and orientation at the onset of the disease, and by the 
absence of mannerisms; from the depressive forms of 
manic-depressive insanity by the absence of psychomotor 

The third group, which is the most severe, begins with 
a condition of pronounced delirium, which soon passes 
into a stuporous state. In spite of improvement in the 
physical condition, the patients continue dull, and in- 
capable of perceiving and elaborating external impres- 
sions. In emotional attitude they are indifferent, quiet, 
or childishly restless and sometimes whining. They lie 
in bed unable to take their food or care for themselves, 
and have to be petted and handled like small children. 

Physically, they fail in nutrition, and occasionally give 
evidence of severe cerebral disorder, especially hemiplegia, 
disturbance of speech, and epileptiform attacks. 

The prognosis is more unfavorable than in other forms ; 
only one-half of the cases recover after an extended course. 


The patients present as residuals, a weakness in will- 
power, a lack of judgment, and they are forgetful and 
indifferent. The condition is distinguished from the 
stupor of the catatonic state by the absence of nega- 
tivism and the stupor of the manic-depressive by the 
absence of retardation. 

The treatment of all these forms consists of rest in 
bed, a most nutritious diet, cleanliness, and careful 

Finally, under this head, we have the psychosis accom- 
panying polyneuritis (Korssakow's disease), which is char- 
acterized by marked disturbance of attention and defective 
memory, with pronounced fabrications. 

The pathological anatomy thus far has revealed a certain 
amount of atrophy in the cortex, due mostly to a marked 
shrinkage in the tangential fibres, in which the cells par- 
ticipate very little. 

Symptomatology. — The onset of the disease is sudden, 
sometimes with a condition of delirious excitement. Pa- 
tients are confused, disoriented, restless, and anxious, es- 
pecially at night. Hallucinations of sight also appear, 
but the prominent symptom is the striking inability to 
remember passing events, in spite of the retention of 
clear apprehension. Incidents of their early life, and 
even events which have happened but a few moments 
before, are not remembered. They do not remember 
having just received a visitor or that they have had 
dinner, have taken a walk, or received a letter. They 
forget having just related an incident, and consequently 
are constantly enumerating over and over again the very 
same facts, asking the same questions, and expressing 
similar desires several times during the same visit. In 
this defect of memory the time element especially is de- 


fective. They cannot tell whether an event occurred 
yesterday, a week ago, or a year ago. These gaps of 
memory are filled in with numerous fabrications. The 
patients relate with all frankness and in all detail 
journeys and visits which they have recently made, 
and speak of children which really do not exist. They 
relate the same incidents with different details, and speak 
of conversations with relatives long dead. If these in- 
consistencies are pointed out to them, they are apt to be- 
come much irritated. In emotional attitude they are 
anxious at first, but later become quarrelsome, irritable, 
or indifferent. Sometimes they are childish and easily 
provoked to whining. Physically, besides the character- 
istic polyneuritic disturbances, there is insomnia, loss of 
appetite, and defective nutrition. 

The course is protracted. In a few cases death ensues 
from paralysis of the heart or through coma. Improve- 
ment appears very gradually, and in a few cases progresses 
to recovery in five to nine months. In other cases after 
the consciousness becomes clear there still remains a pro- 
nounced defect of memory, with perhaps continued fabri- 
cations, irritability, and a great susceptibility to fatigue. 
If alcohol has been the exciting cause, the prognosis is 
less favorable. This form in rare instances has occurred 
without the accompanying polyneuritic symptoms, as the 
result of intoxication in tuberculosis, typhoid, and infec- 
tions of the alimentary canal. 

Diagnosis. — Korssakow's disease is apt to be con- 
founded with dementia paralytica, in which there may 
exist a similarly defective memory with fabrications and 
neuritic disturbances. The differentiation depends upon 
the history of the exciting causes, the more rapid onset, 
and the absence of speech and pupillary disturbances. 


Furthermore, in dementia paralytica the judgment is apt 
to be as much affected as the memory. Senile confusion 
presents a similar picture, but in it the mode of onset is 
different, while silliness and egotism are more striking. 
The treatment is similar to that indicated in the other 
forms, besides attention to the neuritis. 


Kraepelin, Einfluss acuter Krankheiten, etc. Archiv f. Psy. u. 
Nervenkr. 1882. 

Adler, Ueber die in Zusammenhange mit acuten Infectionskrank- 
heiten auftretenden Geistesstoerungen. Allg. Zeitschr. f. Psy., 
Bd. 53, S. 740. 

Lesser, T., Ueber Psychosen nach acuten Infectionskrankheiten 
Diss. Muenchen. 

Roux, Contribution a l'etude du delire des affections febrile. Prov- 
ince Med. 22 Mai, 1898. 

Westphal, A., Ueber Intoxications Psychoses. Charite Annalen, Bd. 
S. 659, 1897. 

Molnar, Karl, Ueber die in Zusammenhange mit acuten Infection- 
krankheiten auftretenden Geistesstoerungen. Wien. klin. Rund- 
schau, Bd. 13, Nr. 19. 

Hurd, Post-febrile Insanity. Am. Jour, of Insanity, XLIX, p. 26, 

Korssakow, Psychosis Polyneuritica. Archiv f. Psy., Bd. 21, S. 669; 
Allg. Zeitschr. f. Psy., Bd. 46, S. 475. 

Mueller, F. C, Ueber psychiache Erkrankungen bei acuten fleber- 
haften Krankheiten. Strassburger Inaug. Diss., Kiel, 1881. 


Nervous exhaustion, which is due to excessive abuse 
and inadequate restoration of nervous elements, gives rise 
to two groups of psychoses ; collapse delirium and amentia, 
and chronic nervous exhaustion. 

Collapse delirium and amentia, which differ only in the 
intensity and duration of the symptoms, develop as a result 
of profoundly exhausting conditions, following most fre- 
quently childbirth, loss of blood, and acute diseases, and 
are characterized by marked psychomotor disturbances, 
with profound involvement of apprehension, and with 
great incoherence of thought. 

Chronic nervous exhaustion (acquired neurasthenia) fol- 
lows prolonged and excessive mental strain, develops more 
gradually, and is characterized by various physical signs 
and moderate psychical disturbance. 

Collapse Delirium 

This psychosis is characterized by an acute onset with 
profound clouding of consciousness, complete disorien- 
tation, great incoherence of thought, dreamy illusions, 
hallucinations and delusions, a rapid course, and a fairly 
favorable prognosis. 

Etiology. — Among the exhausting conditions giving rise 
to collapse delirium, childbirth is the most prominent ; others 
are loss of blood, excessive mental strain, mental shock, 
and deprivation with worry. The acute diseases which 
may lead to this condition are pneumonia, influenza, ery- 



sipelas, measles, and scarlet fever. Oftentimes a fright 
occurring while the patient is in a weak condition acts as 
the exciting cause. Defective heredity is present in one- 
half of the cases. 

Pathological Anatomy. — Unfortunately but few cases 
have been examined pathologically. Alzheimer, 1 in cases 
which seem to belong to this group, found throughout the 
cerebral cortex a fine granular disintegration of the chro- 
matic substance of the nerve cell body, with staining of 
the achromatic substance, and without much involvement 
of the nucleus. 

Symptomatology. — Following a few days of insomnia 
and restlessness, there develops very rapidly a condition of 
motor excitement with clouding of consciousness, dreamy 
hallucinations and delusions. The orientation is quickly 
lost ; everything about the patients change, they are no 
longer at home, but are among enemies and thieves, in 
cathedrals, in heaven or beneath the earth. Numerous 
illusions and hallucinations appear; the designs on the 
carpet assume the form of threatening figures, gas light 
appears like the sun, neighbors are passing to and fro, and 
they hear beautiful music. Cars rush by, their own name 
is called out, and troops approach. 

They become noisy and talkative, the content of speech 
shows great incoherence, sometimes with a flight of ideas, 
many alliterations, rhymes, and repetitions, which are as 
often sung as spoken. They develop numerous delusions 
which are varied, incoherent, changing, and both exalted 
and depressed. They have been tried in court and are 
awaiting their death sentence, have been robbed and are 
now to be poisoned. Christ has appeared to them, announc- 

1 Wanderversammlung d. suedwest Neurolog. u. Irrenraetze zu Baden- 
Baden, 1897. 


ing that they have a mission to perform, they are possessed 
of immense wealth, are about to give a large dinner, are 
married and have given birth to children, or are on the 
way to interview the President. In emotional attitude 
they are much exalted and sometimes erotic, especially in 
puerperal cases; depression with anxiety, however, may 
predominate the emotional tone. Occasionally irritability 
is prominent with exhibitions of passion. 

The motor excitement is very pronounced ; the patients 
remove their clothing, race about the room, overturn 
furniture, pound the door, throw the bedding out of the 
window, and try to get out themselves. They are destruc- 
tive and untidy. Very often they indulge in the most 
reckless and impulsive movements, their whole activity 
seeming to be lost in a mixture of confused impulses. They 
prattle away incessantly, sometimes in a whisper, now at 
the top of their voice, and again gesticulating and clap- 
ping their hands. The attention cannot be attracted. 
Questions asked are rarely answered. Orders are not 
obeyed ; on the other hand, they almost always exhibit a 
purposeless resistance to everything, even to bathing and 

Physically, following the onset and during the height 
of the disease, there is great insomnia. If the patients 
sleep at all, it is only for short intervals. Likewise they 
take but little nourishment, in many cases requiring 
mechanical feeding. The condition of nutrition is very 
poor, and there is a marked loss of flesh and physical weak- 
ness. The skin is cool and pale, the temperature usually 
subnormal, and the pulse weak and irregular. The reflexes 
are usually exaggerated. Tremor is sometimes present, 
and there is some tendency to acute decubitus. 

The course is short, the condition rarely lasting over 


two weeks. The return to consciousness is usually sudden, 
often following a sound sleep. When the patients awaken, 
the hallucinations and illusions have disappeared; they 
are conscious of their surroundings and ask for nourish- 
ment. On the other hand, the condition of motor excite- 
ment disappears gradually. The patients continue to be 
talkative, perhaps showing a flight of ideas, some exalta- 
tion, grumbling, and fretful manners. There is also a 
feeling of physical weakness with the desire to remain in 
bed. As they begin to take nourishment, the weight 
increases rapidly. Relapses are rare. 

Diagnosis. — Collapse delirium is differentiated from the 
condition of epileptic dazedness, in which there is confu- 
sion, disorientation, and many hallucinations, by the pres- 
ence of flight of ideas and aimless impulsive movements 
not associated with ideation. In delirium tremens, which 
may be confused with this condition, the hallucinations, 
which are usually of a religious nature are more fantastic 
and terrifying, animal shapes being present. The atten- 
tion can be held and short coherent responses obtained in 
delirium tremens, which is impossible in collapse delirium. 
The condition of catatonic excitement is of more gradual 
onset, rarely follows exhaustion, the consciousness is com- 
paratively clear, with only slight disorientation, and the 
movements are far more stereotyped. The delirious ex- 
citement of dementia paralytica can be differentiated only 
by the history of preceding mental deterioration, the 
presence of undoubted physical signs, and the extreme ex- 
travagance and absurdity of the delusions. The delirious 
mania of manic-depressive insanity, in the absence of a 
history of previous attacks, is very difficult to distinguish 
from collapse delirium. One can only say that the latter 
is characterized by a greater disturbance of apprehen- 


sion. Amentia is differentiated by the longer course and 
the distractibility of the attention. 

The prognosis is quite favorable. Death occurs in a 
few cases as the result of collapse, especially where the 
exciting cause has been very severe. 

Treatment. — The important indications are to maintain 
nutrition and to reduce excitement. The patients must 
receive a sufficient quantity of light liquid diet, to accom- 
plish which it is often necessary to resort to forced feed- 
ing by stomach or nasal tube. Alcohol in combination 
with milk and egg is extremely valuable, given in doses of 
one to two ounces (forty to sixty grammes). Broths and 
peptonized meats may be added in small quantities. Where 
mechanical feeding is contraindicated because of vomiting, 
or abrasion and hemorrhage of the mucous membrane, 
nutrient enemata can be substituted. Also infusion of 
warm normal salt solution, one to two pints (five hundred to 
one thousand cubic centimetres), give excellent results, espe- 
cially if there is impending collapse. The infusion should 
be given under low pressure in the back, rump, or breast. 
The best means of inducing quiet is by means of a pro- 
longed warm bath. The bath should be given at ninety- 
eight to one hundred degrees, and may last from fifteen 
minutes to one and even several hours. During this time 
cold cloths must be kept on the head. If the patient ex- 
hibits fear in getting into the bath and requires holding, 
the bath can do but little good. In such cases one may 
give a hypodermic injection of hyoscine hydrobromate, 2^0 
to jj^ grain, or sulphonal, fifteen grains, in combination 
with the bath for the first few times. The patients may 
even fall asleep in the bath. Hypnotics are usually 
contraindicated. Next to the bath, alcohol is of the 
most service in producing sleep. In collapse, hot 


coffee by mouth or rectum, strychnia, or digitalis are 

It is necessary that the patient be isolated in a place 
where there is quiet, and sufficient attendance to keep 
him in bed. Mechanical restraint should be withheld ; 
a padded bed or room is preferable. Constant attend- 
ance must be enforced in order to prevent injuries,, and 
this must be observed until convalescence is well estab- 
lished. During convalescence the same indications obtain 
here as in convalescence from any acute disease ; careful 
feeding, in which alcohol should be employed, warm baths, 
and freedom from all forms of excitation. Finally, the 
patients must have completely recovered before being per- 
mitted to take up their former duties. A good index of 
this is found in the weight, which should always return to 

Acute Confusional Insanity (Amentia) 

This psychosis is characterized by the sudden appearance 
of dreamy confusion with numerous hallucinations, delu- 
sions, and motor excitement, following a condition of severe 
exhaustion, and running a favorable course of two or three 
months' duration. 

Etiology. — The etiological factors are similar to those 
in collapse delirium, except that typhoid fever and anaemia 
are more frequent causes. 

Pathological Anatomy. — The post-mortem observations, 
thus far reported, present widespread cellular changes in 
the cerebral cortex. While these lesions, consisting of 
more or less disintegration of the Nissl granules and 
staining of the achromatic substance, both with and with- 
out extensive involvement of the nucleus, are almost 
always present, they cannot be regarded as pathogno- 


monic, as they occur in various somatic diseases. Besides 
the cytological changes, there has also been noticed hyper- 
emia of the meninges and of the brain substance, with 
infiltration of leucocytes into the perivascular and peri- 
cellular spaces, and beginning hyaline changes in the small 
cerebral vessels. 

Symptomatology. — At first the patients are anxious, 
restless, and forgetful, sometimes complaining of numb- 
ness and confusion in the head, and inability to gather 
their thoughts or concentrate their attention. In the 
course of a few days, illusions appear, the confusion in- 
creases and there is complete disorientation. Their sur- 
roundings seem changed, and they do not recognize their 
relatives. There are hallucinations of all the senses. The 
patients see strange faces and hear strange voices, birds 
are flying about, lions are roaring, poisonous powder is 
thrown at them, and they are threatened and cursed by 
strangers. The numerous hallucinations form the basis 
for many depressive delusions, which are dreamy, inco- 
herent, contradictory, and often repeated. Their children 
are dead, the home is lost, the devil has secured them, they 
are to be hung, are under the influence of some magnetic 
power which draws them about, and in the end will con- 
sume them. In a few cases the delusions are expansive ; 
they believe themselves exalted to some high position, 
possessed of great wealth, they have been around the 
world, will convene Congress, and will send an army to 
Cuba. Sometimes they fabricate extensively. 

The patients are unable to apprehend correctly, they 
do not know where they are, mistake friends, and lose all 
track of time. The attention is attracted to the surround- 
ings, they endeavor to grasp what transpires, and it is 
usually possible to direct the train of thought by objects 


held before them, by movements and gestures ; yet they 
cannot understand readily even the simplest occurrences. 
To some of these patients everything is changed, things 
to-day are not the same as yesterday, the chairs and win- 
dows are different, even the nails in the floor are changed, 
they are being served with different dishes, the strokes 
of the clock are not right, the papers are incorrectly 

The disturbance of thought is very prominent. They 
are quite unable to express one thought before others 
interrupt. Words and sounds are caught up from the 
surroundings and find a place in their expression, though 
not necessarily influencing or directing the train of 
thought. Often the content of speech is made up of 
single, incoherent, and disjointed words and phrases. 
Occasionally sound associations and rhymes are heard. In 
spite of distractibility, flight of ideas, and complete inco- 
herence, one occasionally finds the patients holding to 
single indefinite ideas, usually of persecution. The con- 
sciousness is much clouded and dreamy. The persistence 
of clouded consciousness during quiet intervals is a char- 
acteristic feature. 

The emotional attitude varies considerably, sometimes 
with prevailing happiness, but more often with depression. 
Alternations of the attitude are characteristic ; for short 
periods they may be elated, mirthful, and hilarious, with 
perhaps some sexual excitement, when they suddenly 
become excited and irritable, or they may be even dull and 

In the psychomotor field there is a marked tendency 
toward great activity. They move about restlessly, crawl 
in and out of bed, destroy clothing, pound and beat, but 
the actions are not very quick, are performed without 


much energy, are planless, incoherent, and protracted. 
This motor excitement is intermittent. 

Physically, the sleep is much disturbed, the appetite is 
poor, and sometimes there is complete refusal of food, 
especially when great motor excitement is present, or 
where the patients entertain ideas of distress. Other 
physical signs are increased deep reflexes, slow pulse, and 
subnormal temperature. 

Course. — The height of the disease is reached within 
two weeks, during which time there may have been transi- 
tory remissions with clear consciousness and insight. 
From that time the symptoms present a rather character- 
istic fluctuation. The motor excitement may disappear, 
and the thoughts become coherent, when the patients again 
develop excitement with complete incoherence of thought. 
Genuine improvement develops gradually. First the motor 
restlessness disappears, even while there still remains great 
incoherence. Then the patients become oriented, are able 
to gather their thoughts and express themselves cohe- 
rently. Even after they have become clear, long conversa- 
tion or letter-writing tends to develop mental confusion. 
During the first few weeks of the convalescence the emo- 
tional attitude may show a slightly elated or depressed 
condition, seen in hyperactivity and garrulity, or in dis- 
trust, anxiety, and irritability. The entire course extends 
through three to four months. In some severe cases, even 
after the patients have become clear, a few hallucinations 
may persist for a short time, and occasionally indefinite 
expansive or depressive delusions are expressed. In 
actions they will show some constraint, irritability, and 
outbreaks of passion, or they may be haughty and re- 
served. Even after all the symptoms of the disease have 
disappeared, the patients are very apt to show diminished 


power of resistance, greater susceptibility to fatigue, and 
excesses are apt to create relapses. The weight rises 
rapidly during convalescence. 

Diagnosis. — In differentiating this form from other 
psychoses it is necessary to bear in mind the causal condi- 
tion, — exhaustion, — the acute onset, and the characteristic 
symptoms; namely, difficulty of clear apprehension in 
spite of the ability to maintain the attention, delusions 
and hallucinations, distractibility, profound disturbance of 
thought with confusion and sometimes flight of ideas, 
changing emotional attitude, and motor excitement. 

From the maniacal form of manic-depressive insanity, 
amentia is distinguished by the much greater prominence 
of the disturbance of apprehension than of the psycho- 
motor sphere, the former of which persists even after the 
motor excitement has in a great measure subsided, while 
in the maniacal state, in spite of great motor excitement, 
the patients usually give evidence of at least a partial 
comprehension of the environment. In amentia the move- 
ments are slower, more planless, and less precipitous, and, 
in quiet intervals, when they have quite disappeared, the 
patients are still hazy and confused. The condition of 
catatonic excitement is distinguished by the fact that the 
catatonic patients in the midst of the greatest excitement, 
are usually able to comprehend their surroundings, to 
reckon time correctly, to recognize persons, and to record 
some passing events ; and besides this, they present the 
characteristic catatonic signs ; namely, catalepsy, negativ- 
ism, verbigeration, mutism, and stereotyped movements, 
and manners. 

The prognosis is favorable. Death rarely occurs, and is 
due to collapse, heart failure, sepsis, and phthisis. This 
psychosis rarely leads to permanent mental impairment. 


The treatment coincides with that of collapse delirium, 
consisting of forced rest in bed and prolonged baths to 
induce quiet, aided by moderate doses of alcohol. Occa- 
sional doses of hyoscine, trional, sulphonal, bromides, or 
paraldehyde in extreme excitement are of value and better 
tolerated than in collapse delirium. 


Binswanger, Ueber die Pathogenese u. klinische Stellung der Er- 

schopfungspsychosen. Berlin, klin. Wochenschr., Nr. 23 u. 

24, 1897. 
Meynert, Amentia. Jahrb. f. Psy., 1881. 

Meynert, Amentia. Klinische Vorlesungen ueber Psychiatrie, 1890. 
Mayser, Zum Sog. hallucinatorischen Wahnsinn. Allgem. Zeitschr. 

f. Psy. XLII, 1. 
Willie, Die Lehre von Verwirrtheit. Archiv f. Psy. XIX, H. 2, S. 

Chaslin, La Confusion Mentale Primitive, 1895. 
Paulsen, Studier over primar idiopathish Amentia, 1896. 

Chronic Nervous Exhaustion 

The condition of chronic nervous exhaustion is the 
result of excessive mental application continued for some 
time. It is one of the products of civilization, and is con- 
fined largely to the professional and clerical callings, and 
to women of the middle classes. It is characterized by 
irritability, defective mental application, increased sense 
of fatigue, and a great variety of physical symptoms, includ- 
ing hypochondriasis. 

Acquired neurasthenia, as used here in a restricted sense, 
must be clearly distinguished from the congenital or hered- 
itary neurasthenia of the French authors, which is here 
considered as one of the constitutional psychopathic states. 
No doubt there are many transitional states between 
the two diseases, and especially where defective heredity 
and external exhaustion are both prominent factors. 
The difference in the train of symptoms, their course 
and outcome, in individuals free Lorn hereditary taints, 
it seems, are sufficiently distinctive to justify this restric- 
tion of acquired neurasthenia. 

Etiology. — Rapid, irregular, and extravagant manner 
of living, with little relaxation and lack of sufficient and 
wholesome sleep in individuals actively engaged in busi- 
ness or taxed with the responsibilities of the household is 
distinctively characteristic of the American in the temper- 
ate regions, and accounts for the greater prevalence of 



this disease in our people. It is almost as prevalent among 
Russians. Besides excessive mental application, the worry 
attendant upon responsibility is an important factor. It 
appears at all ages, but is most often met between the ages 
of twenty-five to forty-five, the period of life during which 
there is the greatest mental strain. 

At an earlier age it is seen in ambitious students who 
apply themselves too closely to studies without relaxation. 
Neurasthenia occasionally appears after a severe illness or 
mental shock. 

Symptomatology. — The symptoms in both the physi- 
cal and psychical fields are equally prominent. Of the 
mental symptoms, the first to appear is irritability, keenly 
appreciated by the patient, at the beginning overcome by 
the will, but under stress of excitement always coming to 
the surface and causing annoyance. The patients are 
very easily irritated, become unreasonable and fault-find- 
ing. Trivial matters may lead to outbursts of passion 
over which they have no control. At home the frolics 
of the children irritate them beyond endurance. Instead 
of these signs of irritation, one sometimes meets the oppo- 
site condition, when the patients are indifferent, with 
absence of the usual sympathetic feelings, stupid and dull, 
sluggish and sleepy, and overcome with an irresistible 

The capacity for mental application diminishes rapidly. 
The accustomed work is carried out with increasing diffi- 
culty, requiring greater exertion and more frequent rests. 
They are easily distracted by little things and are inatten- 
tive. Twice the usual time is spent in reading the paper, 
and still they are unable to get an idea of its contents. 
They are forgetful with names and figures; columns of 
figures have to be added several times before the correct 


sum is obtained. They are embarrassed by their inability 
to recall the names of well-known acquaintances. The 
trend of thought in a letter or conversation may be 
abruptly broken off and forgotten, much to the chagrin 
of the patient, who tries to continue. The ability to origi- 
nate and create disappears, and the patients find them- 
selves confined to that which is purely routine in thought 
and action. 

There is not only a keen insight into these defects, but 
also a tendency to exaggerate the real symptoms. They 
assert that the memory is becoming profoundly affected, 
and that the judgment is failing. The physical symptoms 
are even more strongly exaggerated, which aids in increas- 
ing their misery. The excessive anxiety about the condi- 
tion of their health leads to a characteristic symptom, 
hypochondriasis , in which there is a tendency to pay 
undue attention to trifling symptoms which may appear 
in any organ. The patients believe that they are suffer- 
ing from some incurable disease, and especially the one 
which they have most dreaded. There may be some gen- 
uine disorder, but the real symptoms are greatly enhanced 
by the habitual attention paid to them. Canker in the 
mouth is considered infallible evidence of syphilis; a 
cloudy urine indicates Bright's disease, and a cough, that 
they are succumbing to consumption. 

The appreciation of their incapacity creates a feeling of 
reserve, timidity, and a lack of self-confidence. They 
cannot trust themselves in public, apprehending fainting 
spells on the slightest exertion. It rarely happens that 
the feeling of despair becomes intense enough to lead to 
suicidal attempts. Associated with the loss of will-power, 
there should also be mentioned the tendency to compulsive 
thoughts and impulsive acts, which sometimes explains the 


suicidal attempts. Here are included the various phobias, 
which are fully described in the constitutional psychopathic 
states. In the strife to overcome impulsive ideas, the pa- 
tients often reach an emotional crisis of short duration, 
with restlessness, wringing of the hands, crying and moan- 
ing, and even attempts at suicide. 

These states are more apt to follow continued excita- 
tions, such as prolonged visits or unusual noisiness. 

Physical symptoms form a very characteristic feature 
of the psychosis. The most important symptoms are 
headache, insomnia, general muscular weakness, paraes- 
thesias, cardiac and gastro-intestinal disturbances. Ceph- 
alalgia^ which appears early, may be expressed as a head- 
ache, a feeling of numbness or a pressure in the head, which 
interferes with work. This is usually situated over the 
eyes or in the occiput, and increases with exertion until it 
becomes unendurable. It is more prominent in the morn- 
ing, passing off during the day. Sometimes there is a 
feeling of pressure, as if the head were held in a vice or 
by a constricting band. It may be associated with ver- 
tigo, dimness of vision, roaring in the ears, or painful 
pressure points in the scalp. 

Insomnia is usually an aggravating symptom from the 
onset. The few hours of sleep, obtained either immedi- 
ately upon retiring, or in the early morning, after hours 
of restless tossing, are unrefreshing and disturbed by 
dreams. The general muscular weakness is always in 
evidence ; they are always languid, and tire easily upon 
walking or from slight muscular effort. 

Subjective sensations are prominent, such as paresthe- 
sias or a feeling of formication in the trunk and limbs. 
Both the superficial and deep reflexes may be increased ; 
rhythmic twitchings and tremor are occasionally noticed. 


The prominent cardiac disturbances are palpitation and 
irregularity of the action of the heart, with occasional 
precordial pain. Associated with the cardiac disturbances 
or occurring independently, there may be vasomotor dis- 
order, cold extremities, localized sweating and blushing, 
or abnormal dryness of the skin. The appetite is variable 
and anorexia is frequent, but the nervous dyspepsia, gastric 
and intestinal, is by far the most prominent digestive dis- 
order. Gastric fermentation, probably due in part to 
deficiency of the digestive fluids, especially hydrochloric 
acid, causes distention of the stomach accompanied with 
discomfort and pain. Extending into the intestines, the 
fermentation gives rise to borborygmy and colicky pains, 
the latter of which may be severe enough to simulate gen- 
uine colic. The digestion is usually not impaired suffici- 
ently to create disturbance of nutrition, but in severe cases 
it may even cause cachexia and anaemia. The intestines 
are usually constipated. Diarrhoeas are apt to appear for 
short periods, and may be persistent for a considerable time. 

In the sexual life there is more often a loss of sexual 
desire, but in a few cases a tendency to excessive indul- 
gence, although at the same time patients complain of 

In cases which resist treatment, the patients become 
chronic invalids of a most distressing type. They go the 
round of physicians, pass from one sanatorium to another, 
taking all kinds of drugs. Mentally they pass into a state 
of lethargy in which all thought centres about their own 
misery. All attempts at business are abandoned, and the 
cares of the household are renounced. They betake them- 
selves to the seclusion of a charitable institution with its 
freedom from annoyances, or if they remain at home, 
demand the utmost consideration for every whim. They 


have no thought for the maintenance of the family or 
appreciation of the burden which they create. The in- 
creasing demand for sympathy leads to prevarications and 
to various assumed contortions, in order to assure the 
physicians or friends that they are in a critical condition. 
The daily greeting from one patient was, " My God, doc- 
tor, I am dying ! Just feel of my abdomen. Have you 
no compassion for a dying man ? ,: A female patient 
remained in bed for years, and when received at the hos- 
pital from the hands of a tender-hearted mother, had not 
had her hair combed in two years, and one of her toe nails 
had grown to the length of five inches. It is this class of 
patients who eventually become habitues of morphin, 
cocain, chloral, antipyrin, and other drugs. 

Course. — The onset of the disease is gradual. It may 
appear suddenly, following an acute disease, especially 
influenza. There is a great variation in the prominence 
of the symptoms. A daily improvement toward evening 
is noticeable, and upon demand they are able to pull 
themselves together for a special occasion; but the follow- 
ing day witnesses an exacerbation of the symptoms. The 
course is usually protracted and the convalescence gradual, 
sometimes extending over years. Patients with a strong 
neuropathic heredity rarely recover the former state of 

Diagnosis. — It is of prime importance to exclude all 
organic disease of the internal organs. The diagnosis of 
neurasthenia should be reached by a process of exclusion, 
after a most thorough physical examination. 

The psychoses which may be confounded with neuras- 
thenia are dementia paralytica, dementia praecox, and 
melancholia of involution. The difficulties in dementia 
paralytica arise only in the first stages of the disease. 


Signs of nervousness without definite cause in a man of 
healthy constitution appearing for the first time in middle 
life should at least arouse suspicion of dementia paralytica. 
In neurasthenia the memory defect varies from day to 
day, is easily corrected upon effort, and does not show the 
defective time element which is so characteristic of the 
memory in the paretic. Neurastheniacs complain of men- 
tal impairment, but are able to amend errors in writing 
and speech, while the apparent mental defect in the 
paretic is unrecognized, or, if recognized, its extent is not 
appreciated. The sensory disturbances of the neuras- 
theniac are subjective, of the paretic, objective. The pres- 
ence of the characteristic nervous disturbances of the 
paretic leaves no doubt : Argyl Robertson pupil, increased 
myotatic irritability, ataxia in speech and gait, tremor 
of the muscles about the mouth and of the tongue, and 
epileptiform or apoplectiform attacks. 

The prodromal periods of the other psychoses, especially 
dementia prcecox and melancholia, are hardly to be distin- 
guished, especially where these psychoses follow some 
acute disease, or appear in neuropathic individuals who 
have succumbed in the struggle with more favorably 
endowed associates. The appearance of apathy without 
sufficient cause, and of delusions of reference or persecu- 
tion without insight, indicates the more serious condition. 

The prognosis depends upon the extent to which the 
exciting causes can be removed, the duration of the 
disease, and the neuropathic basis. Unless the patient 
can be removed from the exciting causes, the chances for 
permanent improvement are poor. 

Treatment. — Where possible, it is the duty of the fam- 
ily physician to bear in mind prophylaxis. Individuals 
who are handicapped by a defective heritage must be 


well guarded during their development, with due attention 
to moral and physical hygiene. Later, when it becomes 
necessary to enter actively into the severer duties of life, 
the limitation of mental application and physical exertion, 
together with the avoidance of worriment and anxiety, 
must be constantly kept in mind. 

In the treatment of the disease after its development, 
the individuality of the physician is of prime importance ; 
he must recognize and utilize his power of influence over 
the patient in addition to various therapeutical agencies. 
It requires confidence in order to inspire the patient and to 
lift him from his morbid anxiety and depression. Isolation 
with a changed routine of life demands immediate atten- 
tion. In the lighter cases, a trip to the mountains or a 
sea voyage to relieve the asthenic condition, or where 
this is impracticable, removal from the customary sur- 
roundings into a quiet, restful, but attractive place, will 
accomplish the same result. Next to isolation, insomnia 
must be combated. Usually the change of the surround- 
ings with different routine relieves this condition. In 
case this fails, one may use alternately the various modern 
hypnotics, sulphonal and trional, etc. But before resort- 
ing to these medicinal means, hydriatics should be thor- 
oughly tried. Of these the most serviceable methods are 
the prolonged warm baths, ninety-eight to a hundred de- 
grees for thirty or forty-five minutes, cold ablutions, the 
spray, the simple douche, and the dripping sheet. In the 
last method, which may be carried out at home, after a 
cold ablution, eighty-five to seventy-five degrees, the pa- 
tient standing in warm water, or on a dry surface, with a 
cold towel about the head, a linen sheet, dipped into water 
seventy-five to fifty-five degrees, is wound dripping about 
the patient, the nurse at the same time applying friction 


until a thorough reaction takes place. The douche, as 
carried out at a bath institution, is of great value. In 
the more severe cases, the secret of successful treatment 
lies in a well-regulated routine suited somewhat to the 
tastes of the individuals, but requiring of all a definite 
amount of sleep, nourishment, mental and physical exer- 
cise, alternated with rest and relaxation, together with 
baths and out-of-door life. All of this may be carried out 
under the supervision of a physician who is willing to 
spend time and thought in caring for the details. The 
relative amount of exercise and forced rest must vary in 
individual cases. The anaemic and debilitated who have 
been exhausted by long suffering or the prolonged care of 
invalids, together with anxiety and worriment, require 
forced rest for a few weeks with a full nutritious diet, 
massage and passive movements. Others need daily 
exercise, which must be purposeful and suited somewhat 
to the tastes. The diet, also, must depend upon the con- 
dition of the nutrition. Where indigestion or constipa- 
tion exists, the usual means should be used to counteract 
these conditions, always giving preference to physical 
agencies. Electricity and massage are of value, but only 
secondary to the above methods. Sometimes local treat- 
ment is called for in correcting uterine troubles, errors of 
optical refraction, or in removing nasal obstructions. 


As already stated, the term intoxication psychoses is 
here used in a narrow sense to include all psychoses aris- 
ing from toxic substances taken into the body. 

They are divided into acute and chronic intoxications, 
according to the length of the time during which the 
toxic substances have been ingested. 

Acute Intoxications 

The acute intoxications are characterized in common by 
a delirious state of short duration, with pronounced psy- 
chosensory disturbance, dreamy fantastic delusions, pleas- 
urable emotional attitude, often with conditions of ecstasy, 
and without much motor excitement. 

The number of toxic substances, including ptomaines, 
which might be mentioned here is large. The transitory 
character and the infrequency of the toxic deliria make 
them of little importance to the clinician. They are, how- 
ever, of great scientific value to investigators, who are 
able to study pathologically and psychologically the effects 
of the different toxic substances. Some of these which 
are characterized by peculiar mental symptoms will be 
mentioned here. The mental state produced by chloro- 
form is characterized by hallucinations of sight only. In 
santonin poisoning there are hallucinations of sight in 
which everything appears yellow ; hasheesh delirium is 
characterized by disturbance of the taste and muscle 



Hasheesh and opium smoking produce a complacent feel- 
ing of well-being, and of a dreamy, pleasurable existence. 
The carbonic acid narcosis is characterized by its short 
duration and the presence of pronounced sexual hallucina- 
tions. In the toxic condition produced by atropin there 
is a severe disturbance of apprehension, with isolated hallu- 
cinations, marked confusion of thought, elated emotional 
attitude, and active motor excitement. The course is 
either fatal or the psychosis clears very quickly with no 
recollection of the events. 

The duration of all these conditions is short, from a 
few hours to a few days at the most. The prognosis de- 
pends entirely upon the severity of the intoxication. In 
diagnosis one must rely in great measure upon the 
knowledge of the circumstances and upon the physical 
signs. The treatment is limited to the employment of 
means to rid the body of the toxic substance, and the 
application of special antidotes. 

The psychosis produced by lead poisoning, encephalo- 
pathies saturninia is more frequent and differs from the 
above delirious states by its longer duration, characteristic 
nervous symptoms, and poorer prognosis. The physical 
symptoms usually precede the mental disturbance ; that is, 
wrist drop, peroneal paralysis, tremor, pains in the limbs, 
and sometimes colic. The immediate prodromes are rest- 
lessness and headache. The onset of the delirium may 
be acute or subacute. There are many hallucinations of 
sight and hearing, great psychomotor disturbance, many 
delusions with great fear, and complete clouding of con- 

The speech is incoherent, and in the height of the de- 
lirium there are frequent reckless impulsive movements. 
There is complete insomnia, and very little nourishment 


is taken. The active excitement is followed by a condi- 
tion of stupor or coma, sometimes antedated by stupor with 

Epileptiform convulsions may also appear, and ambly- 
opia is frequent. The convalescence is gradual, extend- 
ing over several weeks. Some cases terminate fatally in 
coma. While most of the patients recover, there are many 
who, upon regaining clear consciousness, present a degree 
of mental enfeeble ment in which simple apathy is a 
prominent feature. A few present progressive muscular 
atrophy, simulating dementia paralytica. The whole 
duration of the psychosis in favorable cases is from a few 
weeks to three months. 

Chronic Intoxication 

Of the many toxic substances whose continued use leads 

to disturbances of the mind, those best known and of most 

clinical value are alcohol, morphin, and cocain. Almost 

all nations, according to anthropological data, have had a 

drug whose habitual use has been a source of danger to its 

people. It is a striking fact that these substances have 

always been used first for medical purposes, and later 

continued for their exhilarating and alleged supportive 



The acute intoxication of alcohol is described here rather 
than under the acute intoxications, because of its close 
association with chronic alcoholism. 

Acute alcoholic intoxication produces at first a diminu- 
tion of the power of apprehension and elaboration of 
external impressions, and an acceleration in the release 
of voluntary impulses. The perception of simple sensory 
impressions is difficult, sluggish, and uncertain. An 


attempt to solve a simple problem shows a distinct dimi- 
nution in intellectual power. 

In speech one can discern that the association of ideas 
most closely related to the motor elements of speech is 
prominent, such as the use of compound words and 
rhymes. The release of motor impulses is so much 
accelerated that that finds expression most readily which 
is learned by heart. The choice between two movements 
is precipitous, frequently incorrect, and sometimes already 
executed before the proper direction is determined upon. 
Later, or following larger doses, the psychomotor activity 
is displaced by paralysis, the rapidity and extent of the 
paralysis depending both upon the amount taken and the 
susceptibility of the individual. The muscular strength, 
at first slightly increased, is soon much diminished. 

Even small doses influence the capacity for good mental 
work. Thoughts are not easily gathered, rendering the 
solution of complicated problems very difficult. This 
increases with the amount taken. A thoroughly intoxi- 
cated man is unable to comprehend what is said to him 
or what goes on about him, cannot maintain his attention 
or direct the train of thought. He has no conception of 
the significance or the bearing of his actions. The inter- 
nal association of the train of thought is very much dis- 
turbed, as indicated by the tendency to the repetition of 
phrases and the use of commonplace remarks, also in the 
fondness for quoting obscene rhymes and in the use of 
jargon. Finally apprehension may be so far lost that he 
becomes insensible and unconscious. The memory of the 
events of the intoxicated state is very meagre. 

In the psychomotor field, at first, there is a light grade 
of over-activity, with the disappearance of the usual re- 
straints which regulate the actions of our daily life. He 


is active, gay, free and jolly, speaks and acts without 
restraint, and even becomes reckless. The ready release 
of motor impulses promotes the feeling of increased 
muscular strength. Later the motor excitation increases ; 
the facial expression loses its character, each action is 
exaggerated ; the voice is louder, and the smile broadens 
into laughter. He becomes profane, grumbles, and growls. 
He is hasty and passionate, and a single word or a 
trifling accident suffices to start a quarrel or to lead to 
an assault. Finally the excitation, as the disturbance of 
apprehension increases, is replaced by signs of paralysis, 
and there is a profound disturbance of speech, a stagger- 
ing gait, and even complete motor paralysis. 

The emotions at first give way to a feeling of well-being. 
There is a certain degree of exhilaration, and a freedom 
from care. He becomes light-hearted and happy. Later 
irritability appears. The higher moral feelings are lost. 
He is shameless, and with the increased sexual excitability, 
is often led to filthy excesses. 

The duration of the intoxication depends much upon 
the individual. It usually disappears quite rapidly, 
although ill effects may be observed for twenty-four to 
thirty-six hours later; headache, lassitude, nausea, and 
anorexia. Fatigue predisposes to rapid appearance of 
paralytic signs, and even without the intervention of the 
period of excitation. Individuals who are apt to be slug- 
gish and sleepy are apt also to be quarrelsome, aggressive, 
mischievous, and even cruel. 

As the result of experimental investigations of acute in- 
toxication in test animals, Nissl has demonstrated a profound 
change in the cortical neurones, seen in the fading and the 
irregular amalgamation of the Nissl granules, the diminu- 
tion in size and irregularity of the nucleus, whose mem- 


brane and nucleolus may finally disappear. Dehio has 
observed similar changes in Purkinje cells. 

Chronic Alcoholism 

Chronic alcoholic intoxication is characterized by gradual 
and progressive mental deterioration, with many physical 
symptoms, depending pathologically upon a chronic degen- 
erative process in the central nervous system. 

Etiology. — Defective heredity is the most prominent 
etiological factor, and is manifested by a diminished 
power of resistance. Some observers have reported as 
high as eighty per cent, of cases with defective heredity. 
The extensive use of alcoholic drinks by many classes of 
people and the laxness of public sentiment in regard to it 
should also be considered as an etiological factor. 

Pathological Anatomy. — The pathological lesions found 
in chronic alcoholism are equally prominent in the central 
nervous system and in the internal organs. The principal 
lesion is arterio-sclerosis. In the brain, there is regularly 
more or less chronic leptomeningitis and pachymeningitis 
with or without hematoma. The cerebrum is below 
normal in weight, its convolutions more or less shrunken, 
and its ventricles dilated, the ependyma of which in rare 
instances is granular. 

The larger vessels at the base and in the fissures pre- 
sent arterio-sclerotic patches or atheroma, but the most 
characteristic lesion is found in the endarteritis, mostly 
localized, of the small terminal arteries of the cortex, and 
other parts of the brain. The cortical neurones present 
what Nissl has called the chronic change, a gradual 

Nissl, in his experimental research with chronic alcohol- 
ism, in test animals, found a moderate thickening of the 


pia, especially at the base, destruction of many of the 
cortical neurones, with an increase of neuroglia. The 
usual alterations in the other organs are chronic gas- 
tritis, cirrhosis of the liver, chronic nephritis, fatty in- 
filtration of the myocardium, and chronic endocarditis with 
greater or less degree of general arterio-sclerosis. 

Symptomatology. — There is a gradual and progressive 
enfeeblement of the intellectual faculties, in which the 
impairment of memory and of the moral sense is most 
prominent. There also develops a failure of judgment 
and diminution in the capacity for employment. The 
intellectual capacity of the man is first to suffer. The 
power of mental application gradually fails, it becomes 
difficult to maintain the attention, and the sense of fatigue 
increases.. New and unaccustomed work requires unusual 
application and is accomplished only with difficulty. 
Patients prefer to continue in the same old ruts, and are 
indifferent in applying themselves to any mental work. 
Consequently intellectual progress not only ceases, but 
retrogrades, showing an increasing lack in judgment and 
a poverty of ideas, enhanced by a gradual failure of mem- 
ory. Finally there is inability to acquire anything new, 
important facts are forgotten, and the past is recalled only 
as a somewhat confused and distorted picture. This con- 
dition offers a fertile soil for the development of more or 
less pronounced delusions (alcoholic paranoia). 

The moral deterioration is a prominent and character- 
istic symptom. There is a profound change in moral 
character, and the patient soon loses sight of the higher 
ideals of life and the sense of honor. This is especially 
noticeable in their estimation of their own alcoholic habits. 
Their depravity is disregarded with a nonchalance, or it 
is claimed that the liquor, taken for their physical benefit, 


does them no harm. When reprimanded for continued 
inebriety, they accuse a friend of having given them the 
liquor, or claim that they are driven to drink by their 
wives. A faithful promise to abstain from further use 
of alcohol may be volunteered by an habitue ; but when 
an hour or a day later he is encountered coming from a 
saloon, he shows no feeling of shame. 

Some claim that their work needs stimulation ; others 
take only as much as can be regarded as a food. It is 
of interest to note the variety of conflicting excuses offered 
by mechanics for the necessity of taking liquor : the cook, 
the fireman, and the iron moulder require it because of 
the great heat ; while the night watchman, the truckman, 
and the iceman need it to drive off the cold. Many are 
driven to drink by unfortunate circumstances at home ; 
the death of a relative, a sick child, and an ugly wife are 
frequent incentives. 

The patients lose all affection for their families, become 
indifferent to the tears of their children, have little inter- 
est in their welfare, disregard the real infidelity of their 
wives, at the same time developing a certain exaggerated 
feeling of self-importance, noticeable especially in conver- 
sation. They are unable to take matters seriously, and 
display an unnatural sense of humor {drunkard s humor). 

There is a corresponding increase of mental irritability, 
which is more evident during intoxication. Patients are 
quarrelsome, engage in strife and abuse on small provoca- 
tion, misuse their children, and are destructive of cloth- 
ing and furniture. Their complete and abject submission 
when opposed by a superior force or when incarcerated is 
in marked contrast to their behavior at home. Their in- 
offensive behavior and attitude of humiliation before others 
often excites sympathy from the inexperienced. 


They become entirely unstable, cannot remain at home, 
visit from saloon to saloon, tramp from one city to an- 
other, and engage in their usual occupation only for a few 
days or hours at a time, offering the excuse that they are 
physically unfit for continued labor. They leave the sup- 
port of the family to the wife and children, whom they 
browbeat for enough money to keep them in liquor. Others 
degrade themselves by pawning clothing or furniture, or 
even steal in order to satisfy their appetite. 

Physically. — The most prominent physical symptoms 
are fine tremor, noticed first in the finer movements and 
later becoming general ; muscular weakness with atrophy; 
uncertainty in gait; defective speech, sometimes thick, 
sometimes slurring, with occasional aphasic symptoms ; 
frequent headaches and sometimes vertigo. The tendon 
reflexes are often increased, rarely lost. In the sensory 
field there are frequently areas of hyperesthesia and an- 
aesthesia. Epileptic attacks * appear in from one to thirty 
five per cent, of cases, varying according to the observations 
of different investigators. Wildermuth has recorded them 
in only one and five-tenths per cent. They are more fre- 
quent in persons who have been addicted to distilled liquors. 
Magnan, Wartman, and others believe that it is to be 
distinguished from true epilepsy, regarding it simply as 
epileptoid, similar to the convulsions occurring in uremia 
and dementia paralytica. These epileptic attacks are 
rarely permanent, usually disappearing with the with- 
drawal of alcohol. 

Prognosis. — The chances of recovery depend upon the 
extent of mental deterioration and the character of the 
treatment. If the patients already show moral deterio- 
ration, prolonged treatment is apt to be of little avail ; each 

1 Bratz, Alcohol u. Epilepsie. Allg. Zeitschr. f. Psy., S. 234, 1899. 


time they relapse into their former habits, becoming at last 
mental and physical wrecks. Cases when taken early 
and submitted to an extended treatment have a fair pros- 
pect of complete recovery. In many reputable inebriate 
institutions from one-fourth to one-third of their cases 
recover permanently. 

Diagnosis. — The recognition of chronic alcoholism pre- 
sents few difficulties in view of the history, the typical 
facies, and the physical symptoms, the latter being at 
times made more evident by the presence of neuritic 

Treatment. — The successful treatment of chronic alco- 
holism demands complete abstinence from alcohol in every 
form. A few patients are capable of carrying out this 
injunction successfully by themselves, but the vast major- 
ity, and especially those whose occupation brings them 
into bad associations, require the treatment afforded by 
a special institution for alcoholics. The alcohol can be 
suddenly withdrawn except in a few cases where there 
is a disturbance of the heart. The insomnia, anorexia, 
and occasional hallucinations which arise in consequence 
of withdrawal quickly disappear, and in a few days im- 
provement begins, which progresses gradually. Severe 
cases require a hospital residence of nine to twelve months, 
or even longer. An index of the power of resistance may be 
found in their insight into their own condition, and willing- 
ness to prolong their hospital residence. Hypnotic sug- 
gestion has been an efficient means in the hands of some 
physicians in bringing about a more rapid recovery. 

The alcoholic psychoses which develop upon the basis 
of chronic alcoholism are : delirium tremens, alcoholic delu- 
sional insanity, alcoholic paranoia (Eifersuchwahn) and 
alcoholic pseudopareses. 


Delirium tremens is characterized by the sudden de- 
velopment of fantastic hallucinations of sight and hearing, 
indefinite and changing delusions, mostly of fear and ap- 
prehension, often of a religious nature, ivith clouding of 
consciousness, rapid course and good prognosis. 

Etiology. — There is an undoubted relationship between 
delirium tremens and chronic alcoholism, especially in in- 
dividuals addicted to distilled liquors. The fact that the 
symptoms of delirium tremens in no way resemble those 
of acute alcoholic intoxication interferes with the belief 
that it is due alone to alcoholic intoxication. Further, 
the amount of alcohol ingested immediately before the 
attack seems to bear no definite relation to it, as, in some 
cases, the patients have had no alcohol for weeks ; others 
develop the condition only upon its withdrawal, and in 
some it appears in spite of continued drinking. 

The most important factor is a state of defective nutri- 
tion, which usually exists for days, and even weeks, be- 
fore the outbreak. In this gastritis plays an important 
r61e ; the patients take little or no food for days, suffering 
from anorexia, vomiting, and gastric pains. 

In view of these facts it is now the prevailing belief 
that it arises as the result of an intoxication, produced 
by a condition of faulty assimilation and metabolism in 
organs already made susceptible by the long-continued 
use of alcohol. Other exciting causes are shock, injury, 
and acute diseases, especially pneumonia. 



Pathological Anatomy. — There is usually pronounced 
venous stasis, and edema of the brain. Bonhoeffer * claims 
that, while there is no nervous lesion characteristic of 
delirium tremens, there is present in severe cases an ex- 
tensive degeneration of the nerve fibres in the corona ra- 
dialis, especially beneath the central convolutions, and to 
a less extent in the anterior and lateral nerve tracts of 
the cord. There is little or no alteration in the parietal 
and Broca convolutions. The lesions characteristic of 
chronic alcoholism are also found. 

The cell alteration is of an intense degree correspond- 
ing to the severity of the clinical symptoms. He calls 
attention to the dissolution of the chromophilic granules, 
producing a finely granular appearance, to the alteration 
of the staining qualities, and to the change in the contour 
of the cell body. There is an accumulation of glia cells 
about the nerve cells. The protoplasmic processes are 
intensely stained for some distance from the body. There 
are degenerative changes in the pons and medulla, con- 
fined mostly to the posterior columns of the cord and their 
nuclei, seeming to indicate that the degenerative changes 
in the cerebellum are associated with the centripetal fibres. 
The manifold changes in the same brain, and the various 
transition forms, make it impossible to point to any 
change as characteristic. 

Nissl has called attention to certain cell changes which 
remind him of the acute changes ; that is, staining of 
the achromatic portions, especially in the neuraxones, vac- 
uolation of the cell substance, and a moderate swelling. 
There are often found small hemorrhagic points in the 
pons about the nuclei of the ocular muscles. Besides the 
acute changes, the cortical cells usually give evidence of 

1 Bonhoeffer, Monatschr. f . Psy. u. Neur., Bd. V, S. 265. 


chronic alterations, characteristic of chronic alcoholism, 
also an increase of glia cells and chronic vascular changes. 
In the internal organs there is found fatty degeneration 
and fibroid myocarditis of the heart, cirrhosis of the liver, 
and acute and chronic alterations in the kidneys. 

Symptomatology. — The onset of the psychosis is rather 
rapid, following a few days of insomnia and uneasiness, 
a changed disposition, unusual timidity, and perhaps in- 
definite sensory disturbance, indicative of sensory excite- 
ment, such as hyperesthesia, creeping sensations, and light 
specks before the eyes. There may have been a few in- 
definite hallucinations at night. 

The most prominent symptom is numerous hallucina- 
tions of all the senses, especially of sight and hearing. 
These appear in connection with clouding of conscious- 
ness, disorientation, more or less psychomotor excitement, 
and certain motor and sensory nervous symptoms. 

The hallucinations and delusions, which appear first 
during the night, become more prominent, and annoy the 
patients constantly. They are perceived with great clear- 
ness, and, with the terrifying content, produce a marked 
alteration in the emotions. The patients see all sorts 
of animals, large and small, moving about them; rats 
scamper about the floor, serpents crawl over the bedding, 
insects cover their food, birds of prey hover about in the 
air. Fantastic forms are seen, mermaids, satyrs, and huge 
quadrupeds. Crowds press upon them, troops file by. 
The devil and his imps are omnipresent, peering in 
at the windows or crawling from under the bed. They 
hear all sorts of noises : the roaring of beasts, ringing of 
bells, firing of cannons, crying of distressed children. 
They are taunted by passing crowds, are threatened 
with death, are cursed, called traitors, thieves, and mur- 


derers. Paresthesias of the skin lead to the ideas, that 
ants are crawling over them, that bullets have entered 
the body, and even the absence of wounds does not deter 
them from exposing limbs which have been shot full of 
missiles. Hot irons are being applied to their backs, and 
dust is thrown in their faces. They can detect the 
odor of gas, sulphur fumes are being forced through the 
keyhole. Real objects about the room assume life, 
the tufts on the bedding become creeping things, and 
the bedposts demon guards. The content of the hallu- 
cinations and delusions is not always of a terrifying na- 
ture. Sometimes angels are seen, beautiful music is heard. 
God appears to them, announcing that they are Christs, 
and empowered to cast out devils ; they are commanded 
to go to confession and to proclaim the gospel message ; 
they are in beautiful surroundings, are richly dressed, 
in palatial quarters, attended by lovely maidens. Some- 
times the scenes are of a lascivious character. Occasion- 
ally there is a mixture of the fearful and the beautiful, 
but more often, when there is a change of the emotions, 
the former is gradually replaced by the latter, as the 
course of the disease progresses. The hallucinations and 
delusions, in a few cases, and especially after the height 
of the disease has been passed, are nothing more than a 
passing show for the patients ; they gaze at the hideous 
forms and listen to the various noises quite unconcerned. 
The results of various experiments seem to indicate that 
the hallucinations and illusions originate in disturbances 
of the central processes. Hallucinations seen through a 
colored glass are not similarly colored. Also the halluci- 
nations can be made to appear by directing the patient's 
attention to their sensory fields, and by asking them what 
they see and hear. 


The various hallucinations may enter into the picture 
of an occupation delirium, when the patient is busy gather- 
ing up the gold lying about him, driving a flock of sheep, 
leading an orchestra, or addressing a multitude. The per- 
ception, according to Bonhoeffer, remains normal; the 
temperature, pain, muscular sense, and the acuity of sight 
and hearing being intact. The field of vision is occasion- 
ally restricted, and the tactile sensibility somewhat sharp- 
ened. The sense of equilibrium and the perception of 
space is a little uncertain, the patients complaining that 
the floor is shrinking up or that the walls are coming 

Disturbances of apprehension are prominent. There is 
defective interpretation of the impressions excited in the 
various sensory fields, with the result that the patients mis- 
interpret noises, do not recognize pictures, and are unable 
to obtain any sharp and clear impressions. The disturb- 
ance becomes more apparent when the patients attempt 
to read. Instead of correct sentences, there is a senseless 
series of words and sound associations, which is especially 
noticeable when the type is small and indistinct. Some- 
times there is no relation between the reading and the 
subject matter. This same defect is sometimes due to 
aphasic disturbances. The attention of the patients is held 
only with great difficulty. It is usually impossible to gain 
their attention. Forcible language may hold them for a 
short time, but they quickly relapse. The patients note 
only those objects which especially attract them. This 
may explain why their attention is not attracted to severe 
injuries, and how they can use broken limbs recklessly. 

There is always a moderate clouding of consciousness. 
The surroundings are not correctly comprehended. The 
ideas which are excited by occurrences in their immediate 


surroundings are confused and contradictory. Profound 
clouding of consciousness is found only in severe cases. 
The surroundings are mistaken for the bar-room, the church 
for the prison, and strangers are greeted as old friends. 
They have a wrong conception of the time of week, month, 
and sometimes, also, of the year ; usually they over-estimate 
the duration of their illness. 

The memory for remote events is well retained. The 
patients recall correctly where they live and facts concern- 
ing their families and occupation, and the length of time 
they may have resided in different places. But the mem- 
ory for recent events is very defective, especially for the 
time of their occurrence. Occasionally they present 
marked falsifications of memory. 

The train of thought is coherent, yet the patients show a 
distractibility. During a conversation trifling incidents 
lead the train of thought off into various directions. They 
experience difficulty in collecting their thoughts, are unable 
to recognize contradictions, and fail in trying to solve 
problems which require thought. 

In emotional attitude the patients are anxious and fear- 
ful or happy and cheerful, depending upon the character 
of the hallucinations or illusions. They may change rapidly 
from intense fear to jolly laughter, and even indulge in 
witty remarks. In actions they are more or less restless 
and talkative. They are seldom able to engage in work, 
though occasionally a patient continues at his occupation 
until the disease is well established. Usually they take 
an active part in their numerous hallucinations. They 
plug the ears to keep out disagreeable noises, crawl under 
the bed to elude persecutors, escape from the window to 
get away from the sulphur vapors and the enemies wait- 
ing outside the door ; they answer the imaginary voices, 


run to the station for protection, or amuse themselves with 
their beautiful surroundings and join in the happy com- 
pany of imaginary revellers. Sometimes they are asser- 
tive and aggressive, demanding attention or carrying out 
divine commands. When in fear they often commit 

Many chronic alcoholics develop what in their own par- 
lance is called a " touch of the horrors," which in reality 
is an abortive form of delirium tremens. 1 Some of these 
cases come under the care of the family physician, but the 
majority of them go without medical attendance. The 
symptoms are those of the prodromal stage of delirium 
tremens. During a debauch or following abstinence or 
mental shock, there develops some paresthesia, a vague 
feeling of apprehension, as if some one were constantly 
behind the patients, the slightest noise causing them to 
be startled. While in this state they have single hallu- 
cinations of sight and hearing. One patient saw for a 
moment a number of rats scampering across the floor, 
others were attracted by unnatural voices. It very fre- 
quently happens at night that some object appears at the 
window for a second and is gone. The patients are per- 
fectly conscious, and appreciate their condition. The phys- 
ical signs of delirium tremens are usually present. It is 
of short duration, rarely lasting over a few hours or days. 

Physically, besides the various sensory disturbances 
which may form the basis for illusions and hallucinations, 
there is often great muscular weakness. There is ataxia 
and pronounced tremor of the tongue and fingers, and 
sometimes of the extremities and eyelids. Speech is often 
ataxic and paraphasic, with malposition of words and syl- 
lables, and in the severest cases, may be slurring and unin- 

1 Berkley, Mental Diseases. 


telligible. Occasionally in the severe cases muscular 
spasms are noticed. Epileptiform seizures may occur, 
appearing shortly before the attack, sometimes accom- 
panied by transitory paralytic symptoms. The tendon 
reflexes are exaggerated. Insomnia is marked from the 
first, and persists unless the patients become stuporous. 
The condition of nutrition suffers, because of the small 
amount of nourishment ingested, which is due in part to 
the delusions of poisoning, and in part to the gastritis. 
There is apt to be a slight rise of temperature during the 
first few days, rarely reaching one hundred degrees. The 
pulse rate is low as well as the respiration, and occasion- 
ally there is profuse perspiration. 

In a large percentage of cases the urine contains albu- 
men and casts, which clears up with the psychosis ; albu- 
moses are rarely found ; nucleo-albumens are often present. 
Esholz finds in the blood a relative leucocytosis, with a 
diminution of the eosinophiles at the height of the psy- 

Course. — The duration of the delirium varies from a few 
days to two weeks, rarely extending beyond three weeks. 
The improvement comes with sleep. The hallucinations 
usually fade away slowly, though sometimes they dis- 
appear within a night. With the improvement of sleep 
the physical symptoms disappear gradually. The memory 
of the events of the psychosis depends upon the severity 
of the disturbance of consciousness. In the severe cases 
nothing may be recalled. 

Not all cases show the rapid clearing up of symptoms 
with the improvement of sleep. A few cases suffer 
relapses after a few days of clear consciousness have 
intervened. Others show a complete alteration in the 
character of the psychosis after the hallucinations and 


illusions have disappeared, some going over into the char- 
acteristic polyneuritis psychosis, or into the alcoholic delu- 
sional form. A certain number of cases pass into a 
condition of mental deterioration. Here the patients, 
after the hallucinations, the disturbance of consciousness, 
and restlessness, have disappeared, still continue somewhat 
reserved and suspicious. Occasionally a few hallucinations, 
especially of hearing, remain. Likewise changeable 
delusions may persist, as, that they are worked upon by 
electricity. Occasionally expansive delusions are expressed 
for a short time. The memory is well retained, but evi- 
dences of mental weakness are noticed in lack of judg- 
ment and mental apathy. In emotional attitude the 
patients present a mixture of anxiety aud humor. They 
are ordinarily good-humored and tractable, showing some 
weakness of will power, but at the same time easily 
excited to anger. A marked characteristic is the varia- 
tion in the mood. At times they are amiable and indus- 
trious, at the same time recognizing that they are not well, 
while at others they are irritable, complaining, threaten- 
ing, and express hallucinations. 

Diagnosis. — The diagnosis of the disease is not difficult 
if the previous history is known. Fever delirium and the 
dreamy-like conditions of epilepsy may be confused with 
delirium tremens. In the former there is a more marked 
clouding of consciousness, and especially in the epileptic 
condition, confused delusions of a religious character stand 
in contrast to the moderate restlessness without impulsive- 
ness, the active hallucinations, and the muscular tremor of 
the alcoholic. 

The delirium of dementia paralytica is differentiated 
from the alcoholic delirium by the previous history of 
change of character, evidences of failure of memory and 


judgment, physical signs, and the more profound clouding 
of consciousness, with a change of personality. The con- 
ditions of mental weakness following a few cases of delir- 
ium tremens may be mistaken for paranoia, but in them 
there is a lack of progressive systematization of the delu- 
sions, which have but little bearing upon their actions ; 
furthermore there is a partial insight. 

The prognosis is usually favorable. In the unfavorable 
cases (three to five per cent.), the symptoms of mental 
paralysis appear, the patients becoming unconscious, their 
movements uncertain and weak, and the content of speech 
entirely incoherent. 

Treatment. — It is of prime importance to first establish 
the proper nutrition. The condition of gastritis may 
demand lavage with saline solutions. Small quantities of 
liquid nourishment, frequently repeated must be given 
from the onset ; if necessary in order to accomplish this, 
feeding by tube should be resorted to. Insomnia and rest- 
lessness must be combated by the administration of paral- 
dehyde, sulphonal, ortrional. Chloral in repeated doses until 
sleep is procured is successfully employed by some, but very 
many question its use, especially where there is any cardiac 
trouble. Krafft-Ebing recommends repeated injections of 
methylal, one and one-half grains every two or three hours 
until sleep is procured. Where there are severe complica- 
tions or fever, hypodermic injections of three-fourths 
grain of aqueous extract of opium may be employed ; but 
here also its use must be avoided where there is cardiac 
weakness, and furthermore, this drug must never be sud- 
denly withdrawn. The alcohol can be safely withdrawn 
at once, and this procedure, except where there is a tendency 
to heart weakness, when either camphor, strong coffee, or 
strychnin should be substituted, is advisable. With the 


taking of nourishment and the appearance of sleep, the 
condition improves rather rapidly. Constant watching 
is absolutely necessary to prevent the patient from leaving 
the bed and injuring himself or others. During severe 
illness in chronic alcoholism, one should always guard 
against the occurrence of the delirium by maintaining 
nourishment and securing sleep. 


Liepmann, Archiv f . Psy. XXVIII, 570. 
Elsholz, Jahrbucher f. Psy. XV, 2 u. 3. 
Jacobson, Allg. Zeitschr. f. Psy. LIV, 221. 
Bonhoeffer, Monatschr. f. Psy. u. Neur. I, 229. 
Trommer, Pathologische Anatomische Bef uncle bei Delirium Tre- 
mens. Archiv f. Psy., Bd. XXXI, S. 700. 


This psychosis is characterized by the sudden develop- 
merit of coherent delusions of persecution, based upon hallu- 
cinations of hearing ivith retention of clear consciousness. 

Etiology. — The same etiological factors apply to this 
alcoholic psychosis as to delirium tremens. Why one case 
should develop into delirium tremens and another into 
alcoholic delusional insanity is yet unknown. 

Symptomatology. — Occasionally, a few prodromal symp- 
toms, such as indisposition, headache, dizziness, insomnia, 
and irritability, are present before the acute onset. The 
patients at first are disturbed only at night by indefinite 
noises, shouting voices, crying, ringing bells, and firing 
of guns. Later the sounds become more definite, as, the 
call of their own names or separate curse words, and 
finally definite sentences, usually in reference to them- 
selves. These remarks appear to come from the next 
room, or from workmen close by. They may be indistinct 
or clear, and occasionally are heard with only one ear. 
Very often the voices are recognized as those of a chum, 
a fellow-workman, or a well-known policeman, but rarely 
as those of the immediate family. The remarks are usu- 
ally imprecations and references to misdeeds of their past 
life; they are called murderers, liars, thieves, have betrayed 
their native country, or have shot the President. They 
hear that they are to be electrocuted, that the wife is 
unfaithful, that the children have been drowned. They 
are laughed at because of their anxiety. Sometimes all 



of this is heard through a telephone. At times they are 
compelled to listen to their own indictment for murder or 
their death sentence. The content of these hallucinations 
is always of a depreciatory nature, and to it all they are 
unwilling listeners. Besides these numerous hallucinations 
of hearing, there are a few hallucinations of sight, espe- 
cially at night. Strange and threatening forms appear 
before them, some crawling from under the bed, others 
creeping on the wall; brilliant specks come across the 
field of vision and they may even see double. At times 
the food has a peculiar taste, exciting suspicion. 

The patients seem to be the centre of attraction ; every 
one about them watches and threatens them. Their every 
thought and action is known and commented upon. 
Passers on the street jeer at them. Neighbors shoot 
through the fence at them, detectives in citizen's clothes 
follow them wherever they go. They are distrustful of 
their surroundings, constantly on the alert for impending 
arrest, or they go into hiding, refusing to leave their 
home. These patients argue that they are condemned to 
die, and show considerable emotion. The night nurse is 
regarded as a hangman, and his entrance into the room is 
resisted to their utmost strength. Fellow-patients refuse 
to speak to them because they are implicated in the seduc- 
tion of their wives. Sometimes they refuse to answer 
questions or associate with any one until brought to the 
court room for the supposed trial. At times they find 
consolation in prayer and in reading the Bible. 

The consciousness is unclouded. The patients are ori- 
ented, their speech is coherent, and they are able to make 
an accurate statement of their symptoms. They rarely 
possess clear insight, but may realize that they are differ- 
ent, and frequently accuse their, persecutors of drugging 


them or making them crazy. Others claim that they are 
" nervous." 

The emotional attitude is usually depressed, but at times, 
and especially later in the course of the disease, there is a 
mixture of anxiety and cheerfulness when they relate their 
frightful experiences with indifference, or perhaps laugh at 
the absurdity of their attracting so much attention. At 
the onset they are anxious and fearful. Many apply for 
protection at the police station. They are apt to be seclu- 
sive, avoiding attention. A cigar maker abandoned his 
position and kept to his room many days for fear of detec- 
tives who were after him. When not constantly in fear, 
they are quiet, reserved, and in replying to questions are 
monosyllabic. Their actions are well directed, and they 
are often able to help in ward or home duties. It is not 
rare for them to continue at their employment for several 
days after the outset of the psychosis. 

Physically, sleep is regularly disturbed by hallucina- 
tions and anxiety. The appetite fails and there is a loss 
of weight. The reflexes are occasionally exaggerated and 
tremor of the tongue and hands is often present. 

Course. — The course of the psychosis may be either 
acute or subacute. When acute, the duration varies from 
two to three weeks, with rapid disappearance of the symp- 
toms, sometimes during a night. In the subacute form 
the symptoms may persist from one to eight months, with 
numerous remissions, disappearing gradually. Hallucina- 
tions other than those of hearing, and the appearance of 
expansive delusions, indicate a prolonged course. 

The diagnosis of the disease depends upon the alcoholic 
history, the acute onset, and the prominence of hallucina- 
tions of hearing, upon which are based coherent delusions 
of persecution, without clouding of consciousness. Cases 


of dementia prcecox and dementia paralytica may present 
similarities, but are differentiated by the more sudden 
onset of the alcoholic psychosis, the lack of uniformity in 
the emotional attitude, seen in the mixture of anxiety and 
cheerfulness, and the great predominance of hallucinations 
of hearing without disturbance of consciousness. The 
presence of mannerisms, constrained postures, definite 
changes in the emotional attitude from depression to 
cheerfulness, following the content of the delusions and 
the clouding of consciousness, would indicate dementia 

Prognosis. — The outcome is usually favorable, only a 
few cases failing to recover. These present the picture of 
a light grade of deterioration, similar to that following 
some cases of delirium tremens ; a few maintain expansive 
and persecutory ideas. 

The method of treatment is similar to that indicated in 
delirium tremens. 

Alcoholic Paranoia 

A few cases of chronic alcoholism gradually develop 
delusions of jealousy {Eifersuchwahri), independently of 
ideas of persecution, which are persistently adhered to 
and expanded with poor attempts at systematization. 

The estrangement naturally arising between man and 
wife as the result of chronic indulgence in alcohol and its 
necessary consequences, is the nucleus about which delu- 
sions of jealousy form. The patients believe that the rea- 
son for this change of affection lies in the fondness of the 
wife for other men, or of the husband for other women. 
Added to this, Krafft-Ebing lays considerable stress upon 
the failing sexual powers of the alcoholic. Iscovescu 1 

1 Iscovescu, These, Paris, 1898. 


found the delusions of jealousy three times more prevalent 
in females than in males, which he explains by the fact 
that women are more emotional. Insignificant occur- 
rences are regarded as important evidence of this infidel- 
ity : the assistance of some one in carrying a bundle, the 
fondness of a friend for their children, the voluntary im- 
plication of a neighbor in a family strife. The frequent 
clanging of a car bell means that the motorman is a core- 
spondent. A side glance from a passer on the street, the 
arrival of an unusual letter, and even association with 
another man's wife, are held as sufficient proof of the 
suspected misbehavior. Furthermore, the home and chil- 
dren are neglected. They have seen the wife enter the 
apartments of a neighbor, and from noises which they 
have heard are sure that she was guilty of infidelity. 

Occasionally, peculiar noises are heard about the house, 
a creak of the door or low talking, which are supposed to 
be made by the lover. There may be a peculiar odor in 
the house, or an odd taste in the food, which leads them 
to believe that an effort is being made by the wife to 
poison them. This incites them to nail down the win- 
dows and to fasten the door in order to keep out intrud- 
ers. The saloon keeper is implicated, if he refuses to 
give them credit for liquor, or the coachman if he happens 
to be amiss in any of his duties. The reasoning in these 
delusions is very weak, illogical, and full of absurdities. 

Their delusions are not built out, but remain con- 
fined within narrow limits. The patients, however, state 
them coherently, and oftentimes display considerable emo- 
tion, and indeed, in this way they frequently convince 
chance acquaintances of the great injustice done. Asso- 
ciated with these delusions of infidelity there may be 
delusions of poisoning. 


There is no clouding of consciousness. In actions the 
patients usually exhibit marked weakness; they bemoan 
their misfortunes while submitting to the injustice. At 
times the actions are entirely out of accord with their 
delusions, and this is especially true in cases of long dura- 
tion. A man may live peaceably with his wife whom he 
accuses of committing adultery night after night in his 
presence. Only rarely do they take means to chastise the 
wife or assault the supposed lover. One patient in despair 
drowned himself. Sometimes they are very irritable, and 
in fits of anger may be both aggressive and destructive. 

The course of the disease is usually progressive. The 
delusions seldom disappear permanently, though absti- 
nence from alcohol often produces improvement, espe- 
cially in conjunction with confinement in an institution. 
When removed from home they are not annoyed as much 
by their delusions, and are able to live very comfortably. 
The apparent improvement leads to the belief that they 
are suitable for release, but the return to home sur- 
roundings, with the opportunity to secure alcohol, soon 
leads to recurrence of delusions. This psychosis is differ- 
entiated from paranoia by the lack of system in the delu- 
sions and by the symptoms of chronic alcoholism. 

The treatment of these cases is limited to abstinence 
from alcohol, and confinement in an institution to prevent 
aggressive attacks and suicide. 

Alcoholic Pseudoparesis 

There may develop in chronic alcoholism a condition 
very similar to dementia paralytica; indeed, the similarity 
is so pronounced that the diagnosis may remain in doubt 
for a long time. It is of gradual onset, with the charac- 
teristic alcoholic hallucinations and delusions of persecu- 


tion and infidelity, together with the characteristic failure 
of memory and judgment, expansive delusions, and mental 
stupidity of the paretic. Physically, there are the disturb- 
ances of speech, muscular tremor, ataxia, occasional epi- 
leptiform attacks, sensory disturbances, and exaggeration 
or loss of tendon reflexes. 

The course of the disease is protracted, but not progres- 
sive. The more marked symptoms disappear in the course 
of a few months, or even years, leaving the patient in a 
condition of mild dementia, with perhaps a few expansive 
or depressive delusions of a paranoid type. A few patients 
recover so as to return to their homes and business. 

The diagnosis depends in great part upon the course, 
which in dementia paralytica is progressive, while in 
alcoholic paresis the symptoms remain at a standstill. 
Furthermore, real muscular weakness is more marked than 
in paresis, and the tremor more general. The difficulty 
of speech in the alcoholic is due to tremor, and does not 
include elision and omission of syllables. Also headache, 
hallucinations, and anaesthesia are more marked in alco- 
holism. In alcoholics the delusions are of fear, persecu- 
tion, and infidelity, with more or less marked emotional 
display, while in paresis, if similar delusions exist they are 
less sustained, coherent, logical, and more easily diverted. 
The paretic regards his woes more philosophically, show- 
ing contentment and indifference. It must be borne in 
mind that typical dementia paralytica sometimes develops 
in the course of chronic alcoholism. 

The pathological findings in alcoholic paresis are, ac- 
cording to Krafft-Ebing, based upon one of his own cases 
similar to those of dementia paralytica, except for the 
absence of the granulations of the ventricles. 



Wachsmuth, Paralysenaehnliche Intoxication Psychosis. Marburg, 

Llewe, Ueber Alkoholische Pseudo-Paralyse. Allg. Zeitschr. f. Psy., 

Bd. 52, S. 595. 


The extensive use and abuse of morphin for its allur- 
ing effects place it only second to alcohol in the produc- 
tion of mental and physical wrecks. 

Etiology. — The intolerance of pain with people of this 
age, together with the freedom of the physicians in dis- 
pensing analgesics, accounts in part for the extensive use 
of this drug. Being an expensive drug, its victims are 
limited to the better classes. Considerably over one-half 
of the patients are those who are best acquainted with its 
ill effects — physicians, dentists, and professional nurses. 
At least one-half of these patients are men. On the Con- 
tinent it is claimed that seventy-five per cent, are men. 

An important etiological factor is the defective consti- 
tutional basis, evidences of which in very many cases are 
earlier manifested by various neuroses, as hysteria. Indi- 
viduals free from this hereditary taint usually succumb to 
the drug after its continued employment in persistent 
painful affections, as neuralgia, sciatica, rheumatism, 
headache, dysmenorrhoea, and different forms of colic. 
The pleasurable feeling and the mental stimulus which 
supplement the analgesic effects are here the cause of its 
continuance. The majority of cases develop between the 
ages of twenty-five to forty years. 

Pathological Anatomy. — In animals to which morphin 
had been administered for a prolonged period, Nissl has 
demonstrated a shrinkage of cortical neurones with an 
increase of the neuroglia. 



Symptomatology. — Acute Morphin Intoxication. — The 
physiological action of morphin is to first produce an 
acceleration and excitation of the process of comprehen- 
sion and a psychomotor retardation, which later passes 
into a dreamy state, with changing fantastic hallucina- 
tions and an intense weariness in the psychomotor func- 
tions. Then ensues a quiet, pleasurable feeling, which 
acts as one of the strongest enticements for the habitue. 
For him it also produces a necessary stimulus for mental 
work, which cannot be accomplished by the exercise of 
the will power alone. There usually develops a metallic 
taste in the mouth, and sometimes rumbling in the 
bowels. Fortunately the drug fails to produce these 
pleasurable effects for all, owing to idiosyncrasies. Many 
after its exhibition suffer from a disagreeable fulness in 
the head, general feeling of discomfort, nausea, and col- 
icky pains. Following the intoxication there is apt to 
be headache, profuse perspiration, and diminution in all 
of the secretions of the body. 

Chronic Morphin Intoxication. — In the prolonged use 
of morphin the effects of acute intoxication disappear, 
and the individual obtains only the exhilarating and the 
quieting effects, which aid in endurance of annoyance 
incident to his work or his home life. The beneficial 
effects of this drug diminish with usage, and soon necessi- 
tate increased dosage, which may, in time, reach from 
thirty to fifty grains daily. The frequency of the doses 
must also be increased, which soon compels the physician 
to intrust the administration of the drug to the patient. 

The character of the symptoms and the time of their 
appearance depend mostly upon the individual constitu- 
tion and its powers of resistance. Some continue addicted 
to morphin throughout life without pronounced ill effect ; 


others succumb in the course of a few months. In these 
the memory weakens, and the capacity for mental appli- 
cation diminishes. Difficult and exhausting work becomes 
impossible without its administration. Consequently the 
patients are either in a condition of exhilaration or stupid- 
ity or nervous irritability, none of which are compatible 
with mental work. 

Emotionally, these patients exhibit many variations: 
they are sometimes dejected, irritable, cross, hypochon- 
driacal ; sometimes confidential, over nice, with pronounced 
affectation ; and occasionally anxious, especially at night. 
Morally, there is a pronounced change of character, notice- 
able especially in reference to their irresistible habit. They 
willingly submit to all sorts of depraved means in order to 
secure the drug. Finally all idea of personal responsibil- 
ity vanishes. The home and the business suffer alike, and 
they fall into a state of apathy and indolence, with an ab- 
sence of will power and energy. They are careless about 
the dress and the personal appearance. In actions they 
are apt to be sleepy during the day, and active and rest- 
less at night, reading, busying themselves about foolish 
trifles, and talking incessantly. They are also disagree- 
able, faultfinding, and obstinate to the extreme. Very 
many of them become addicted to alcohol, and other 
drug habits. 

Physically, the sleep is much disturbed. The patients 
lie awake for hours, their minds busied with all sorts of 
fantastic ideas, sometimes accompanied by genuine hal- 
lucinations of sight. Disturbances of sensibility are usu- 
ally present, such as paresthesias and hyperesthesias, 
especially about the heart, the intestines, and the bladder. 
There is usually an increase of the tendon reflexes. The 
movements are uncertain, tremulous, and sometimes ataxic. 


Occasionally there is difficulty in speech, also paresis of eye 
muscles (double vision and defective accommodation). The 
general nutrition suffers, and there is loss of weight. The 
skin is flabby and dry, due in part to the absence of 
normal secretions. The appetite, especially for meat, 
fails, though sometimes there is a ravenous appetite. Dry- 
ness of the mouth creates unusual thirst. In the cir- 
culatory system there is noticed palpitation, and slow, 
irregular pulse. The ringing in the ears, numbness, 
vertigo, and syncope, as well as the profuse perspira- 
tion and shivering, are attributable to vasomotor dis- 
turbances. The lack of sexual desires and impotence 
are prominent symptoms ; in women there is amenorrhoea 
and sterility. The ensemble of these symptoms creates 
the picture of premature senility. 

Abstinence Symptoms. — The abrupt withdrawal of mor- 
phin in individuals who are addicted to large doses produces 
in the course of a few hours a characteristic train of symp- 
toms called abstinence symptoms. These, according to 
Marme, are due to the action of oxydimorphin. The with- 
drawal in milder cases, however, is always attended with 
more or less disturbance. The patients become tremulous 
and uneasy, experience a tickling sensation in the nose 
and begin to sneeze ; feel oppressed, complain of paresthe- 
sias of different parts of the body, and are sleepless. 
The administration of hypnotics, especially chloral, at 
this time, only increases the excitement and aids in 
bringing about a delirious condition with hallucinations 
and dreamy confusion. In spite of precaution, however, 
a condition very similar to delirium tremens may appear. 
This condition lasts but a few hours, or at most a few 
days. Occasionally there appears a condition of dazedness, 
with hallucinations and convulsive movements. Physically 


the patients display involuntary movements, twitchings 
of the limbs, spasm of the diaphragm, paresis of the 
muscles of accommodation, tenesmus, paleness and flush- 
ing, vomiting, palpitation of the heart, fainting and col- 
lapse with heart failure, which is sometimes fatal. The 
secretion of saliva and perspiration, which during the 
ingestion of morphin has been diminished, now becomes 
excessive, and there is colliquative diarrhoea. Albumen 
is usually present in the urine. The duration and intensity 
of the symptoms depend upon the constitution of the 
patient, the duration of the habit, and the size of the 
habitual dose. The symptoms disappear gradually, except 
in the lighter cases, where they may vanish rapidly after 
a prolonged sleep. In the course of a few days, perhaps 
weeks, the patients begin to sleep and develop an appetite, 
but from this point convalescence progresses very slowly. 

Course. — The rapidity with which the symptoms of 
chronic morphinism develop varies with the power of 
resistance of the individual and the quantity of morphin 
ingested ; in some cases it requires a few months, in others 
several years. The duration also varies ; some die within 
a year of inanition, heart failure, or in collapse, while 
others live for many years in spite of large and increasing 

Diagnosis. — The disease may be recognized by the vary- 
ing emotional attitude ; periods of mental freshness and 
unusual energy with a feeling of well-being, alternating 
with great weariness, stupidity, dejection, and irritability, 
and furthermore by the physical signs : the loss of sexual 
power, anorexia, myosis, and general muscular weakness, 
amounting in some cases almost to paresis. Scars from 
the hypodermic injections should always be looked for. 
The surest means of diagnosis is seclusion or close surveil- 


lance for a week, during which time the demand for the 
drug or some abstinence symptoms, will appear. 

Prognosis. — The prognosis is always very serious. 
Less than ten per cent, recover permanently ; relapses are 
the rule. A few cases die from over-doses of the drug. 
The greater danger lies in cardiac weakness, which may 
lead to sudden collapse and fatal termination. The drug 
may be withdrawn with the proper precautions and the 
patients suffer no ill-effects. Often, when the patients 
do not relapse into morphinism, they revert to substitutes, 
of which the most important are cocain, alcohol, chloro- 
form, ether, and chloral. The treatment is preeminently 
unsuccessful in those with strong neuropathic tendencies. 

Treatment. — The only successful method of treatment 
is complete abstinence. For this purpose the first requi- 
site is isolation in a reputable institution. This method 
of treatment, however, cannot be safely undertaken in all 
cases, and especially where conditions of physical weakness 
are present, also during pregnancy, acute and severe 
chronic diseases. There are two methods of withdrawal, 
the gradual and the rapid, the latter of which requires the 
greatest skill and is by far the most efficacious. The 
former involves much time and patience, and is apt to 
create chronic and disagreeable traits which in the end 
are as difficult to eradicate as the habit itself. For these 
reasons only the rapid method is outlined here. It is nec- 
essary that the patients be placed in bed. In mild cases 
the drug may be withdrawn abruptly. Even in these the 
abstinence symptoms may appear. In cases where the 
dose has been large, the quantity is immediately reduced 
one-half, and after twenty-four hours to a nominal dose of 
one grain daily for several days, and in the course of two 
weeks entirely withdrawn. During the period of with- 


drawal the drug is best given in single daily doses in the 
early evening. If previously taken hypodermically, the 
drug should at once be changed to administration by 
mouth. Abstinence symptoms occur within the first 
thirty-six to forty-eight hours after the withdrawal of 
the drug and demand careful watching on the part of the 
physician. To guard against these and to add to the com- 
fort of the patient, alcohol in small doses with light nutri- 
tious diet may be given. Where there is impending 
collapse, faradization of the skin, injections of ether or 
camphor, the administration of hot coffee or hypodermic 
injections of strophanthus and strychnia are indicated, 
the last of which is often essential. If these fail, one 
always finds immediate relief in return to the usual dose 
of morphin. The greatest restlessness and insomnia 
often yield to the influence of ice packs on the head. If 
unsuccessful, the various hypnotics may be tried. The 
local pains may also be relieved by the application of ice. 
Purgation should be applied early ; this, however, is con- 
traindicated by pregnancy or an acute or serious or chronic 
disease. Diarrhoea demands no special attention. Finally, 
it requires many months, and in some cases a year, to 
reestablish the former mental and physical health so that 
they are able to return to their old associations without 
fear of relapse. Even after being fully reestablished in 
health, it is necessary from time to time that the patients 
be subjected to close surveillance to ascertain if there is a 
return to the old habit. 


Cocain, in distinction from alcohol and morphin in its 
effects, is characterized by the great rapidity with which 
it produces profound mental enfeeblement and physical 
inanition. It is of rare occurrence to encounter alone 
symptoms of cocainism, because of the frequency of its 
complication with alcoholism and morphinism. For this 
reason it is difficult to draw a pure clinical picture of the 

Etiology. — The conditions giving rise to cocainism are 
similar to those encountered in morphinism. Most of the 
patients have a strong neuropathic basis, and many of 
them have previously been addicted to morphin. Early 
in the history of cocainism the habit arose from the sub- 
stitution of cocain for morphin in the treatment of the 
latter habit, but at the present time most of the patients 
are physicians or druggists. The usual method of admin- 
istration is by the syringe, although it may be taken by 

Symptomatology. — Acute Cocain Intoxication. — Cocain 
in small doses produces moderate mental excitement, with 
a feeling of warmth and well-being, increase of pulse 
rate, and a fall of blood pressure. Its effects in the 
psychomotor field are similar to those of acute alcoholic 
intoxication : an excitement followed by paralysis. The 
patient is active, energetic, feels impelled to write, and is 
talkative. This condition is sooner or later followed by 
drowsiness. Large doses lead to delirious states with a 



tendency to collapse. Nissl has found in experiments 
upon rabbits that in the acute intoxication there is but 
a very slight alteration in the cortical neurones ; i.e. a 
moderate disintegration of the chromophilic granules, 
some staining of the achromatic substance, and a moderate 
increase of the glia cells. 

Chronic Cocain Intoxication. — In one accustomed to 
the prolonged use of the drug, there is a continous mental 
state of nervous excitement with a flight of ideas, complete 
incapacity for mental work, lack of will-power, and defective 
memory. The patients are over-energetic, but their activity 
is planless ; they are talkative and very productive, writing 
lengthy meaningless letters, and evolving on paper imprac- 
ticable schemes. They neglect their professional and home 
duties, also their personal appearance. In emotional attitude 
there is a variation between exhilaration with a pronounced 
feeling of well-being and great irritability and anxiety. 
They are very apt at times to mistrust their surroundings. 
At the same time they exhibit more or less indifference 
as to the legal consequence of their acts. The memory 
becomes defective and the judgment much impaired. 

Physically , the most prominent symptom is the pro- 
found disturbance of nutrition; the patients lose weight 
very rapidly, the normal expression changes, they look 
sleepy and tired, the skin becomes flaccid and pale. This 
is due in part to the fact that the drug supplies the place 
of nutritious food, for which they have lost all desire, 
and in part to the excessive glandular action which makes 
a continuous drain upon the body tissues. There is mus- 
cular weakness and increased myotatic irritability, noted 
sometimes in the muscular twitchings. The pupils are 
dilated, but react normally, and there is tremor of the 
tongue. In the circulatory system there is slowness of 


the pulse, palpitation, and a tendency to faintness. In 
spite of increased sexual excitement, the sexual power 
diminishes. The sleep is disturbed, and occasionally 
interrupted by hallucinations. 

Upon the basis of chronic cocainism there may develop 
a definite psychosis which bears close resemblance to the 
alcoholic delusional insanity. 

Cocain Delusional Insanity. — Following a few days 
of irritability with anxiety and some restlessness, there 
appear suddenly hallucinations of different senses; the 
patients hear threatening voices compelling them to 
act strangely, and see moving pictures on the wall, 
which are filled with large and small objects. Charac- 
teristic of the hallucinations are the minute black specks 
moving about on a light surface, which are mistaken for 
flies, mosquitoes, and other tiny objects. This, accord- 
ing to Erlenmeyer, is an evidence of multiple disseminated 
scotoma. Peculiar sensations in the skin create the belief 
that they are being worked upon by electricity, being thrust 
with needles, or that poisonous material is being thrown 
upon them ; but most characteristic is the sensation that 
foreign objects are under the skin, especially of the ends of 
the fingers and the palms of the hands. The muscular 
twitchings, they believe, are due to the action of some 
poison. The hallucinations of hearing make them suspi- 
cious of their surroundings. Their thoughts are being read 
by means of some secret contrivance ; they are being spied 
through holes in the ceiling. Some patients become so 
thoroughly frightened that they attempt to kill their sup- 
posed persecutors, or in despair may commit suicide. 

A characteristic symptom is the silly delusions of infi- 
delity. These are frequently obscene in character. Wives 
are accused of illicit relations with men, of receiving many 


love letters, of stealthily leaving the house and neglecting 
the family for immoral purposes, or of becoming known 
as public characters. In reaction to these ideas they are 
usually vindictive and may even become aggressive. 

The consciousness remains clear. There is good orien- 
tation, except in rare instances where the excitement is 
very great, or immediately following fresh injections of 
the drug. In emotional attitude patients are always 
dejected, excitable, irritable, and sometimes passionate. 
Occasionally they are reserved and reticent concerning 
their delusions. In actions they are usually very restless 
and unstable, though some may appear quite orderly. In 
the markedly delirious conditions which sometimes appear 
there is always great restlessness. 

Cocain delusional insanity develops rapidly and may run 
its full course within a few weeks. The symptoms increase 
rapidly under the influence of single doses of cocain. The 
delirious state soon disappears after the complete with- 
drawal of the drug, sometimes within a few days, while 
the delusions may remain for weeks or even months. The 
coexistence of morphinism and cocainism in the same indi- 
vidual, which is of common occurrence, frequently leads to 
a combination of the symptoms. Morphinism alone seldom 
produces a rapid development of pronounced mental dis- 
turbance, unless in connection with cocainism. 

Cocain delusional insanity is differentiated from alcoholic 
delusional insanity by its more rapid development, the 
greater severity of the symptoms, and by the fact that the 
delusions of jealousy appear earlier and as an acute symptom. 
The effect of a single dose of cocain during the psychosis 
produces an exacerbation of the symptoms, while in alco- 
holism it has little or no effect. Finally, the sensation of 
objects under the skin is characteristic only of cocainism. 


The prognosis in cocainism is unfavorable for complete 
recovery. The symptoms of intoxication clear up after 
the withdrawal of the drug, but the power of resistance is 
profoundly affected, and few resist temptation for any 
great length of time. 

Treatment. — The only successful method of treatment 
is complete abstinence. The rapid method of the with- 
drawal, similar to that employed in morphinism, is best. 
The withdrawal is usually attended only by unimportant 
symptoms, such as uneasiness, a feeling of pressure in the 
chest with difficulty in breathing, also palpitation of the 
heart, and insomnia, and occasionally by a tendency to 
faintness which simulates collapse. If such emergency 
arises, it is necessary to employ stimulants, as alcohol, 
camphor, coffee, strychnia, etc. The insomnia may 
be combated with prolonged warm baths, sulphonal, 
trional, and also by a nutritious diet. An essential ele- 
ment in successful treatment is confinement in an insti- 
tution, where it can be determined with certainty that the 
patient does not have access to the drug. Prolonged treat- 
ment with the employment of every possible means to 
fortify him against relapses is an important factor, which 
requires patience on the part of the patient and persever- 
ance and tact on the part of the physician. If morphin- 
ism and cocainism coexist, cocain should be withdrawn 


Erlenmeyer, Ueber Cocainsucht. Deutsche Med. Zeitschr., Berlin, 

1886, VII, 483. 
Thomsen, Chariteannalen, XII, 1887, S. 405. 
Heymann, Berlin, klin. Wochenschr. XXIV, S. 278. 
Obersteiner, Wien. klin. Wochenschr. 1888, 19. 
Saury, Annales Medico-Psychologiques, 1889, 439. 


The two forms of psychosis arising from disturbance of 
the thyroid gland are myxoedematous insanity and cretin- 
ism. They develop directly as the result of an absence of 
glandular activity, cretinism appearing in early childhood, 
and myxoedematous insanity in adolescence and later. 

Mental Disturbance op Myxcedema 

The mental disturbance characteristic of myxoedema is 
that of a simple mental deterioration accompanied by the 
characteristic physical symptoms of the disease. 

Etiology. — The lack of glandular activity in the thyroid 
is supposed to be the exciting cause by failing to neutralize 
or care for some toxic product of metabolism. The gland 
in all cases is found atrophied or diseased. This is fre- 
quently the result of connective tissue increase, sometimes 
of colloid degeneration, and rarely of tuberculosis or 
syphilis of the gland. 

Symptomatology. — The onset of the mental disturbance 
is gradual, with increasing difficulty of apprehension. The 
patients do not comprehend written or spoken language as 
well as formerly, and are unable to collect their thoughts. 
It takes them longer to perform ordinary duties, such as 
dressing, and they also tire easily. Memory for recent 
events becomes defective. The increasing difficulty in 
applying the mind and in performing even simplest acts 
finally renders them completely helpless. There is no 
clouding of consciousness. At first they exhibit some 



insight into their defects, but later this gives way to in- 
difference and stupidity, not only in reference to them- 
selves and their condition, but also to their environment. 
They rarely express pleasure or pain, and very seldom give 
evidence of thought for themselves or their future. In 
emotional attitude it is characteristic for them to be 
anxious, dejected, and at times fearful. Sometimes they 
develop restlessness and moderate excitement with stub- 
bornness. In rare cases there may appear conditions of 
confusion with hallucinations and delusions. 

Physically , they present characteristic cutaneous and 
nervous symptoms. The skin becomes thick and dry, 
rough, inelastic, obliterating the characteristic lines of 
expression in the face, producing thick lips, broad nose, 
and deforming the hand and fingers. The mucous mem- 
brane is similarly involved, and the tongue is thick and 
unwieldy. The cutaneous change is most marked in the 
supraclavicular region, in the upper arms, and in the 
abdominal wall. The voice is changed, becoming rough 
and monotonous, and the speech is slow and difficult. The 
nervous symptoms consist chiefly of headache, vertigo, 
fainting, convulsive spells, and a fine tremor. Finally the 
skin and mucous membrane become anaemic and very 
sensitive to cold ; menses cease, and temperature becomes 
subnormal. The blood changes vary ; sometimes there is 
an increase of the red corpuscles, and at other times a 

Course. — The psychosis is of gradual onset, and unless 
appropriate treatment is applied, progresses to advanced 
deterioration, extreme physical weakness and profound 
disturbance of nutrition, the disease terminating fatally 
through the intervention of some intercurrent disease. 
Occasionally there are intermissions, and in a few cases 


marked improvement occurs in spite of the absence of 

Treatment. — The administration of dried thyroids of the 
sheep, beginning at one and one half grains, one to three 
times daily, may be regarded as a specific remedy in this 
disease. The dose is gradually increased, guarding care- 
fully against intoxication symptoms, indicated by head- 
ache, dizziness, and irregular cardiac action. The 
improvement becomes evident within a week and increases 
very rapidly. The patients become active and show an 
interest in themselves and surroundings ; they improve in 
memory and in judgment. The physical symptoms im- 
prove with equal rapidity. In the most successful cases 
the patient appears quite well at the end of two months, 
except for some lassitude, which persists for a long time. 
Not all cases recover through medication ; the number 
of unsuccessful cases is difficult to ascertain at present. 
Eelapses may occur. 


Ewald, Die Erkrankungen der Schilddriise, Myxoedem u. Cretinism, 

Buschan, Ueber Myxoedem und verwandte Zustaende, 1896. 


Ceetinism is characterized by a more or less high-grade 
defective mental development, associated with loss of 
function of the thyroid, and accompanied by definite 
physical symptoms. 

Etiology. — The disease is mostly endemic in moun- 
tainous regions. In Europe the cases are most numer- 
ous in the Alps and Pyrenees ; in America, in Vermont. 
Sporadic cases occur as the result of congenital absence 
of the gland or its atrophy during or following a fever, or 
in connection with goitre. The disease arises from an 
organic infectious material, and is in some way associated 
with disease of the parathyroid gland. It is unknown 
whether this infectious organism is the cause of an 
atrophy, a non-development, or disease of these glands, 
in this way producing a failure of mental development ; 
or whether it is due to the direct action of the organism 
or its toxin upon the nervous system. Other important 
factors are defective neuropathic basis and unhygienic 

Pathological Anatomy. — The morbid anatomy is still 
doubtful. Asymmetries and dilatation of the ventricles of 
the brain and atrophy have been found, also hyperostosis 
of the cranium. The cortical neurones are deficient in 
number and processes, and are of the stunted globose form 
peculiar to idiocy and other forms of defective develop- 

Symptomatology. — The symptoms of the disease are 



first noticed during the first and second years, except in 
a few cases where the children are born goitrous. At 
that time they appear dull, stupid, indifferent, sleepy, and 
unable to care for themselves ; have not learned to walk 
or talk, and are slow and awkward in their movements. 
The gland increases in size from the sixth to twelfth year 
in three-fourths of the cases ; in the remaining it dimin- 
ishes. Mentally, the patients fail to develop, presenting 
the symptoms of imbecility ; they are dull, stupid, inca- 
pable of apprehending or of elaborating impressions, pre- 
senting about the capacity of a five-year old child. They 
are rather indifferent and phlegmatic, and quite incapable 
of applying themselves to any work. A few cases pre- 
sent a condition of extreme stupidity. Their condition 
remains unchanged throughout life, except as interrupted 
by short periods of excitement, similar to those occurring 
in idiocy. This condition may form a basis for the devel- 
opment of other psychoses, especially manic-depressive 

Physically, the long bones fail to develop in length, 
instead, becoming thicker. The head is large, and the 
neck short and thick. The nose is broad, and the ears 
are prominent, the skin is thickened as if padded, and in 
places, especially in the neck, hanging dependent in folds. 
The broad face, with heavy cheeks and eyelids, with thick 
lips and broad short nose, presents a very characteristic 
picture. The limbs are large and pudgy. The tongue is 
thick and clumsy in its movements. The hair is scanty, 
and dentition is late and the teeth poor. The speech 
consists of inarticulate sounds, which are loud, coarse, 
slurring, and stammering. The movements are unwieldy, 
the gait slow and cumbersome. Convulsions are rare. 
The sexual organs develop slowly, and in severe cases 


remain entirely undeveloped. Patients have little power 
of resistance, readily succumbing to intercurrent diseases. 
Treatment. — The hygienic surroundings must be im- 
proved with special attention to drinking water. Many 
observers agree that it is advisable as a prophylactic 
measure to send children and families with cretinoid ten- 
dencies to the high mountains, which may bring about 
a complete recovery in children who already show some 
signs of disease. Potassium iodide in small doses seems 
to be beneficial. According to recent observation the ad- 
ministration of desiccated thyroid, if given early, may aid 
in preventing the development of the disease. After an 
extended duration the same drug may improve some of 
the physical symptoms ; thickness of the skin and amenor- 
rhoea, but the mental symptoms cannot be altered. 


Bailarger et Krishaber, Cretin, cretinisme et goitre, endemique. 

Dictionnaire encylopedique des sciences medicales, 1879. 
Bircher, Volkmanns klinische Vortraege, Nr. 357. 
Cristiani, Annali de freniatria, 1897, 349. 
Jentsch, Allg. Zeitsehr. f. Psy. LIV, 776. 
Bourneville, Progres medical, 1897, 10 u. II. 
Osier, Sporadic Cretinism. Amer. Jour. Med. Sci., 1893, Vol. CYI, 

p. 503. 


Dementia precox is the name first applied by A. Pick, 1 
in 1891, to a group of cases including the hebephrenia 
of Hecker and Kahlbaum, characterized by maniacal 
symptoms followed by melancholia and rapid deteriora- 

Since then the meaning of the term has been extended 
so as to include a larger group of cases appearing in earlier 
life, characterized by a progressively chronic course with 
certain fundamental symptoms, of which progressive men- 
tal deterioration is the most prominent. Some psychiatrists, 
especially the Italian, use the name primary dementia, 
because it enables them to include a few cases character- 
ized by similar symptoms which appear in patients long 
past the period of pubescence. The group of cases as 
understood by us is a large one, and includes, besides 
hebephrenia, the catatonia of Kahlbaum and certain forms 
of paranoia which undergo early deterioration. 

Etiology. — The disease is one of the most prominent, 
compromising from fourteen to twenty per cent, of all 
admissions to institutions. As the name indicates, it is 
a disease of early life. More than sixty per cent, of the 
cases appear before the twenty-fifth year. There is, how- 
ever, a difference in the various forms ; in hebephrenia 
almost three-fourths of the cases appear before the twenty- 
fifth year, in catatonia sixty-eight per cent., and in the 
paranoid only forty per cent. In the hebephrenic form 

1 A. Pick, Prager med. Wochenschr., 1891. 


sixty-four per cent, of the cases are men, in catatonia, and 
paranoid forms women slightly predominate. Defective 
heredity is a prominent factor, as it appears in about 
seventy per cent, of cases. It varies somewhat in the 
different forms, being more prominent in the paranoid 
and catatonic, and least in hebephrenic forms. Acute 
diseases, especially typhoid and scarlet fever, act as the 
exciting causes in a small percentage of cases (ten per cent.). 
Head injuries precede a still smaller number of cases. A 
number of patients present mental peculiarities from youth 
up, such as seclusiveness, precocious piety, impulsive 
actions and great susceptibility to alcohol, and at least 
seven per cent, have always been weak-minded. Various 
physical stigmata are occasionally encountered, such as 
asymmetries, malformation of the ears and palate, puerile 
expression, and strabismus. 

Pathology. — It seems probable, judging from the clini- 
cal course, and especially in those cases where there has 
been rapid deterioration, that there is a definite disease 
process in the brain, involving the cortical neurones. In 
a few cases this is a reparable lesion, but in most cases 
the impairment of function is permanent and progressive. 
This pathological basis finds clinical expression in the few 
cases that recover and the larger number that show a 
permanent mental defect. The means by which these 
assumed changes are brought about in the nervous system 
is unknown. In consideration of the close relationship 
with the age of puberty, the presence of disturbances of 
menstruation, and the frequent appearance of the disease 
for the first time during pregnancy and puerperium, further 
assumption is made that it is the result of autointoxication. 
It is also to be noticed that many cases of imbecility 
develop a psychosis different in no essential particular from 


dementia praecox at the age of sexual development, and 
furthermore that epileptics and idiots at the same age 
show a tendency to undergo a decided mental deteriora- 
tion. The total absence of any definite external cause, 
except in isolated cases, adds weight to this belief. As yet 
no one with the present methods of research has been able 
to demonstrate an anatomical pathological basis for the 
disease. Defective heredity, as well as imprisonment and 
acute diseases, is presumed to act by lessening the power 
of resistance to autointoxication. 

Symptomatology. — The disease picture appears so varied 
that upon superficial observation the fundamental symp- 
toms are not recognized. These symptoms, however, per- 
mit of an early recognition of the disease process and 
become more and more marked as the disease progresses. 

In the field of apprehension there is usually very little 
disturbance. External impressions are correctly perceived, 
the patients being able to recognize their environment and 
to comprehend most of what takes place about them. This 
explains the fact that they remain quite well oriented, as 
to time, place, and person. During the acute or subacute 
onset of the disease, apprehension is affected, and there is 
some disorientation. This may also appear during transi- 
tory stupor or excitement; but even in these conditions, and 
especially in the apparent stupidity and indifference which 
characterize the later stages of the disease, it is surprising 
to see how many things in the environment are perceived. 
It is not unusual to find that they notice changes in the 
physician's apparel, in the furniture, or in the landscape. 
Nevertheless, as the disease advances and deterioration 
appears, apprehension, as well as other mental phenomena, 
becomes perceptibly impaired. 

Occasionally delusions entertained by the patient lead to- 


a misinterpretation of some of their surroundings. They 
may be days or years ahead of the correct time, their 
nurses may be called by fictitious names, or the hospital 
may be regarded as a nunnery, while in other respects the 
orientation is correct. 

Apprehension is always more or less distorted by hallu- 
cinations, especially in acute and subacute development of 
the disease. These usually disappear later in the course 
of the disease, but may persist into the end stages. Hallu- 
cinations of hearing are most prominent, next come hallu- 
cinations of sight, and at rare intervals we find those of 
touch. Hallucinations at first are distressing, resulting in 
fear ; but later in the course of the disease they do not 
excite much interest, and the patients when questioned 
are unable to give much information about them. Some 
patients seem to take pleasure in listening to the voices, 
whose communications are both incoherent and silly. 
During exacerbations of the disease the hallucinations 
may induce the former fear and distress. 

Consciousness is usually clear, but in conditions of excite- 
ment and stupor there is always some clouding of con- 
sciousness. It is, however, much less marked than one 
would judge from superficial observation, as the patients 
later are able to give some details of things that happened 
in the interval. 

On the other hand, there is pronounced impairment of 
voluntary attention, which is one of the most fundamental 
symptoms. The controlling force of interest is altogether 
lacking, so that the presentation which happens to be the 
clearest and most distinct at any given moment is an 
accident of passing attention, never persistent enough to 
occasion connected activity. In spite of the fact that the 
patients perceive objects about them correctly, they do not 


observe them closely or attempt to understand them. In 
deep stupor and in the stage of deterioration it is abso- 
lutely impossible to attract the attention in any way. In 
the catatonic form of dementia prsecox the presence of 
negativism inhibits all active attention. This becomes evi- 
dent as the negativism gradually disappears. The patients 
emerging from this condition are caught stealthily peep- 
ing about when unobserved, looking out of open doors or 
windows, and following the movements of the physician, 
but when an object is held before them for observation 
they stare vacantly about or close their eyes tightly. 

There is a characteristic and progressive, but not pro- 
found, impairment of memory from the onset of the disease. 
Memory images formed before the onset of the disease 
are retained with remarkable persistence, — retention is 
good. Though their reproduction is increasingly more 
difficult, unusual stimulation or excitement may occasion 
the recollection of events long since supposed to be effaced 
by the advance of deterioration, — recollection is not free. 
The formation of new memory images is increasingly diffi- 
cult with the advance of the disease. Memory for recent 
events is poor. Events previous to the onset, especially 
school knowledge, may be recalled after the patients show 
advanced deterioration. One patient had a remarkable 
memory for geography, having retained the population, 
area, and some of the physical characteristics of almost all 
of the countries of the world. Such facts are almost al- 
ways recited parrot-like. Some few patients keep a care- 
ful account of the length of their residence in the hospital 
and elsewhere. Events during stupor and excitement are 
not remembered at all, or at most indistinctly. 

In the earlier stages of the disease thought shows a 
characteristic incoherence and looseness. One finds even in 


the mild cases some distractibility, a rapid transition from 
one thought to another without an evident association, 
and interpolation of high-sounding phrases. In severe 
cases there is genuine confusion of thought with great 
incoherence and the production of new words. In cases 
of the catatonic form especially, we meet with evidences 
of stereotypy ; the patients cling to one idea, which they 
repeat over and over again. Besides, there is occasion- 
ally noticed a tendency to rhyme or to repeat senseless 

In judgment there appears from the onset a progressive 
defect. While patients are able to get along without dif- 
ficulty under familiar circumstances, they fail to adapt 
themselves to new conditions. Owing to their inability 
to grasp the meaning of their surroundings, their actions 
are irrational. This condition of defective judgment be- 
comes the basis for the development of delusions. The 
patients believe that they are the objects of persecution, 
and they may have delusions of reference and self-accusa- 
tion. The lack of judgment becomes still more apparent 
in the silliness of their delusions. At first the delusions 
may be rather stable, but later they tend to change their 
content frequently, adding new elements suggested by 
the environment. Even relatively persistent delusions 
are constantly taking on new meanings. Furthermore, 
the delusions, which at first are of a depressive nature, later 
may become expansive and grandiose. In most cases the 
wealth of delusions so apparent at first gradually disap- 
pears. A few delusions may be retained with further 
elaboration from time to time, but they are usually ex- 
pressed only at random. During exacerbations the former 
delusions, whether depressive or expansive, may again come 
to the foreground. In the paranoid forms, however, there 


persists from the beginning a great wealth of delusions, 
but these become more and more incoherent. 

The disturbance of the emotional field is another of the 
characteristic and fundamental symptoms. There is a 
progressive, more or less high-grade, deterioration of the 
emotional life. The lack of interest in the surroundings 
already spoken of in connection with the attention may 
be regarded as one phase of the general emotional deterio- 
ration. Very often it is this symptom which first calls 
attention to the approaching disease. Parents and friends 
notice that there is a change in the disposition, a laxity in 
morals, a disregard for formerly cherished ideas, a lack of 
affection toward relatives and friends, an absence of their 
accustomed sympathy, and above all an unnatural satis- 
faction with their own ideas and behavior. They fail to 
exhibit the usual pleasure in their employment. 

As the disease progresses the absence of emotion becomes 
more marked. The patients express neither joy nor sorrow, 
have neither desires nor fears, but live from one day to 
another quite unconcerned and apathetic, sometimes si- 
lently gazing into the distance, at others regarding their 
surroundings with a vacant stare. They are indifferent 
as to their personal appearance, submit stupidly to uncom- 
fortable positions, and even prodding with a needle may 
not excite a reaction. Food, however, continues to attract 
them until deterioration is far advanced. Indeed, it is not 
unusual to see these patients go through the pockets and 
bundles of their friends for goodies, without expressing a 
sign of recognition. This condition of stupid indifference 
may be interrupted by short periods of irritability. 

Early in the disease, and especially during an acute and 
subacute development, the emotional attitude may be one 
of depression and anxiety. This may later give way to 


moderate elation and happiness. The latter, however, in 
a few instances prevails from the onset. Yet emotional 
deterioration remains a fundamental symptom. 

Parallel with the emotional disturbances are found 
disturbances of conduct, of which the most fundamental is 
the progressive disappearance of voluntary activity. One 
of the first symptoms of the disease may be the loss of 
that activity which is peculiar to the patient. He may 
neglect his duties and sit unoccupied for the greater part 
of the day, though capable of doing good work if persist- 
ently encouraged. Besides this characteristic inactivity, 
there may appear a tendency to impulsive acts. The 
patients break out window lights, tear their clothing into 
strips, leap into the water, break furniture, throw dishes 
on the floor, or injure fellow-patients, all of which seems 
done without a definite motive. These states usually 
pass off very quickly, though in some this tendency may 
be more marked for a period of a few days. 

The inability to control the impulses is also present in the 
stuporous conditions, and especially in the catatonic form of 
dementia prsecox. Here each natural impulse is seemingly 
met and overcome by an opposing impulse, giving rise to 
actions directly opposite to the ones desired. In this 
condition, which is called negativism, the patients resist 
everything that is done for them, such as dressing and 
undressing, they refuse to eat when food is placed before 
them, to open their mouth or eyes when requested, or to 
move in any direction. In extreme conditions there may 
even be retention of urine and faeces. This condition varies 
considerably in intensity at different times. It is not 
unusual to see the patients suddenly relieved of it, 
assume their former activity, talking freely and attending 
to their own needs, and again after an interval of a 


few hours or days relapse gradually into the negativistic 

Still another condition is produced by the repeated 
recurrence of the same impulse, giving rise to a great 
variety of stereotyped movements and expressions. The 
verbigerations and mannerisms of the catatonic are ex- 
plained in this way. The patients repeat for hours simi- 
lar expressions, utter monotonous grunts, tread the floor 
in the same spot, dress, undress, and eat in a peculiar and 
constrained manner. While these symptoms vary consider- 
ably in individual cases, it is unusual not to find at least 
some of them present in every case. 

The capacity for employment is seriously impaired. 
The patients may be trained to do a certain amount of 
routine work, but they utterly fail when given something 
new. A few patients display artistic abilities, as, for 
instance, in drawing or in music, but their efforts are 
characterized by eccentricities. They may show some 
technical skill, but their productions exhibit the absence 
of the finer aesthetic feelings. 

Physical Symptoms. — Most prominent is the disturb- 
ance of nutrition. The patients suffer from anorexia, and 
lose in weight. The sleep is usually much disturbed. 
The heart's action is sometimes retarded, sometimes accel- 
erated, and often weak and irregular. Occasionally 
vasomotor disturbances have been noticed, such as cyano- 
sis, dermographia, and excessive perspiration. In many 
cases there has been detected a diffuse enlargement of the 
glands. The menses almost always cease. The pupils 
occasionally are dilated, and especially during conditions 
of excitement and stupor. The tendon reflexes are usually 
increased as well as the myotatic irritability. All of 
these symptoms tend to disappear later in the course of 


the disease, when the patients develop a good appetite, 
take on weight, the menses reappear, and the skin assumes 
its normal condition. Some observers have reported 
fainting and epileptiform attacks in eighteen per cent, of 
cases. Hysteroid convulsions and paralyses and localized 
contractures have also been noted. 


The onset of the psychosis in this form varies. In a 
few cases it is so insidious in origin that the relatives are 
unable to place the date of the appearance of the first 
symptom. Usually the patients complain first of head- 
ache and insomnia, then a gradual change of disposition 
comes over them. They lose their accustomed activity 
and energy, becoming self-absorbed, shy, sullen, and seclu- 
sive, or perhaps irritable, obstinate, and careless. They 
may become rude and assertive, or they may be perfectly 
indifferent. They are careless of their obligations, are 
thoughtless and unbalanced. They accomplish nothing, 
but rather sit about unemployed, apparently brooding or 
engaging in useless conversation, or they leave their work 
to go to bed, lying there for weeks without evident reason. 
Others, instead of this inaction, exhibit a marked restless- 
ness, and continuous effort is impossible. They leave their 
work, stroll about or ride wheels from place to place, 
especially at night. Others, with increased sexual passion, 
indulge in illicit and promiscuous intercourse. 

During this period, which may extend through several 
months, there are apt to be remissions, when for a short 
time the patients improve greatly and may even appear 
natural. Women show premonitions of the disease during 
the menses. 

More often the onset is characterized by a period of 
depression, when the symptoms appear more rapidly and 
are more pronounced. Here the patients become more 



apprehensive, dejected, sad, and sometimes suspicious. 
They are troubled with thoughts of death, life seems to 
have lost its charms, and friends appear indifferent. Their 
mental condition at this time often leads to suicidal 
attempts. Hallucinations, especially of hearing, and less 
often of sight, appear at this period. The patients are 
annoyed at strange noises, unintelligible voices, unfavor- 
able comments upon their personal appearance ; they hear 
threats and imprecations, music and singing, telephone mes- 
sages, and commands from God. They may also see heav- 
enly visions, crosses on the wall, dead relatives, frightful 
accidents, and deathbed scenes. Occasionally they smell 
various odors, especially illuminating gas and sulphur. A 
patient may experience various hyperesthesias which lead 
him to believe that his head is double, that the throat or 
nose is occluded, that the genitals are being consumed, or 
that the bowels are all bound together. 

Preceding the appearance of the hallucinations, and 
accompanying them, there develops a tendency to the 
formation of delusions, which are almost always of a 
depressive character. The patients believe themselves 
guilty of some crime, accuse themselves of being mur- 
derers, claim that they are lost, are damned, are unfit to 
live, have practised self-abuse, and can never recover 
from its ill effects. They suspect their surroundings, 
detect poison in the food, are being worked upon by 
others, their thoughts are not their own, friends have 
turned against them and are trying to do them harm, 
some one is watching them constantly, and they are being 
harassed by various agencies. Women are followed by 
men who would ravish them. Later in the course of the 
disease, and occasionally from the onset, the delusions are 
expansive; the patients regard themselves as prominent 


individuals, the President, the Son of God, the Creator, the 
possessor of the universe, they converse with God, are the 
Saviour of men, have all knowledge imparted to them or 
can stop all wars by lifting their hands. Some of these 
patients are controlled by sexual ideas. They fancy that 
they are betrothed to prominent individuals of the opposite 
sex. Men believe themselves possessed of many wives, or 
regard themselves as the centre of attraction for all 

These delusions may be augmented by numerous fabrica- 
tions ; the patients claiming that they have been President 
for a century, chief commandant in various engagements, 
have been knighted, that they have been in heaven, have 
possessed the key of hell, have just returned from a visit 
to Mars, where there is eternal war. These fabrications, 
together with delusions, gradually recede to the back- 
ground. At first they become fewer, less fantastic, then 
incoherent, and still more scanty, until finally in the 
advanced stages of the disease there remain only incoherent 
residuals, which may never be expressed except as the 
result of questioning or during excitement. 

Some insight into their condition is often expressed at 
first by the patients. They are conscious that a change 
has come over them, and often complain that the head 
feels strange, benumbed, and empty. These may be ex- 
pressed in connection with somatic delusions, the patients 
saying that the brain is rotting, the memory is failing, 
that they are different in every way and are very much 
confused. Even this scanty insight gradually disappears 
as the disease progresses. 

In those forms of the disease which develop slowly 
there is at first neither clouding of consciousness nor marked 
disturbance of orientation. In the acute or subacute onset 


cloudiness and general disorientation may unite in the 
clinical picture with pronounced hallucinations and delu- 
sions, anxiety and restlessness and incoherence of thought. 
The patients mistake persons, do not appreciate where they 
are, and are unable to record passing events. The physi- 
cians are regarded as enemies, trying to kill them, working 
upon them with electricity, etc. They are confined in a 
prison for some grave offence, or are among the heavenly 
hosts, surrounded by saints. A patient, although he recog- 
nized the physician, still believed that both the physician 
and himself had been entrapped in a prison and that they 
must hasten to escape. 

The association of ideas is at first very little disturbed, 
the content of speech being both coherent and relevant, 
but later in the disease with progressive deterioration 
thought suffers profoundly. The ideas become disconnected 
and incoherent. Questions fail to elicit anything more 
than monosyllables, or entirely irrelevant remarks. 

The memory from the onset presents a progressive dete- 
rioration, at first mostly for recent and passing events. 
The memory of earlier life and the chronological order 
of events is well retained for a long time. Some of 
the patients are able to tell with surprising accuracy the 
exact definitions in geography and many historical events 
almost word for word, as committed to memory years 
before. The events dating from the onset of the psychosis, 
with notable exceptions, such as time of admission to hos- 
pital, etc., are not remembered, or at best only imperfectly. 

The patients may be able to control their attention, but 
they do not try to do it. There is a total lack of interest. 
Without this there is no incentive for observation and 
thought, and they fail to observe what is going on about 
them. As the disease progresses, there is increasing limita- 


tion of thought. For this same reason their past experi- 
ences are seldom recalled, and so finally fade from their 
memory ; though it is not unusual for them, in reaction to 
unusual stimulation, to recall events that seemed to have 
entirely passed from them. 

The defect in judgment appears early, develops rapidly, 
and becomes profound. This may not be so evident while 
the patient is confined at home, or during the early part of 
his residence in an institution, as long as his thought is em- 
ployed with familiar facts and his range for action limited. 
It becomes apparent, however, when he leaves the trodden 
path and attempts to adapt himself to new circumstances. 
He is unable to reason, to perform mental work, to recog- 
nize contradiction, or to overcome obstacles. The defect 
can also be seen in his tendency to formulate and hold to 
senseless, incoherent delusions. 

In emotional attitude the most prominent and permanent 
feature is that of emotional dulness and indifference. 
Whenever we do find emotional activity it is increasingly 
self-centred. At first there is usually more or less depres- 
sion, with anxiety, peevishness, and often irritability. 
Exaggerated expressions of religious feelings are apt to be 
prominent, the patients being devout, praying frequently, 
reading their testaments, at first apparently in the spirit of 
penitence, but later because they are led by God or ordained 
to do some special work. The sexual feelings very often 
play a prominent role, particularly in those who have been 
addicted to the habit of masturbation. Thought may cen- 
tre about sexual matters ; they enjoy obscene literature, 
write long letters to acquaintances, giving expression to 
their lascivious feelings, they masturbate and solicit inter- 
course. The female patients are more apt to associate 
with their own sex. In both sexes these feelings are apt 


to disappear later in the course of the disease. Later in 
the disease the delusions, both expansive and hypochon- 
driacal, are expressed without display of emotion. They 
fail to express emotion at the loss of friends, at the visits 
of relatives, or at an unusual supply of food, fruit, or can- 
dies. They live a very empty life, devoid of any cares or 
anxieties, and without thought for the future. 

In conduct and behavior, the most characteristic symptom 
is that of childish silliness and senseless laughter. The 
voluntary activity is inconsistent and lacks independence. 
At one moment they are increasingly headstrong, at the 
next as supremely tractable. They neglect their personal 
appearance, perform all sorts of outlandish and foolish 
deeds, such as prowling about all night, setting fire to 
buildings, throwing stones to break windows, travelling 
about without evident purpose. They may even run away 
and secrete themselves, or as unexpectedly demand some 
one in marriage, forget their obligations, and finally are 
completely incapable of continued and comprehensive em- 
ployment. A young man was found throwing stones into 
trees because the voices of evil spirits annoyed him. A 
student ran from his mates to a graveyard and covered 
himself with leaves in order to obtain aid in committing 
his ivy oration. A girl of fourteen attempted to stab her 
lover, believing him unfaithful. A young married woman 
solicited intercourse among gentlemen friends, even bring- 
ing them to her home for that purpose in the presence of 
her husband and children. 

The patients are very often seen to converse with them- 
selves, sometimes aloud, while associated with this there is 
almost always silly laughter. This silly laughter is a very 
prominent and characteristic symptom. It is unrestrained, 
appears on all occasions without the least provocation, and 


is altogether without emotional significance. Besides these 
actions, mannerisms, such as peculiarities of speech and 
movements, eating and walking, are often present. A few 
of the mannerisms characteristic of the catatonic may pre- 
vail : echolalia, echopraxia, stereotyped expressions and 

Their speech presents peculiarities indicative of loose- 
ness of thought and confusion of ideas. Their remarks 
may be artificial, containing many stilted phrases, stale 
witticisms, foreign expressions, and obsolete words. The 
incoherence of thought becomes most evident in their long 
drawn out sentences, in which there is total disregard for 
grammatical structure. The structure changes frequently, 
and there are many senseless interpolations. All this be- 
comes even more apparent in their letters, which are ver- 
bose with frequent repetitions, while the handwriting is 
characterized by a marked lack or a superfluity of punctu- 
ation marks, shading of letters, and copious underlining. 

Physical Symptoms. — During the onset of the dis- 
ease the condition of general nutrition suffers. There is a 
loss of weight, and some patients even become emaciated. 
The appetite is poor. Patients eat sparingly or not at all, 
restrained by suspicion and fear, or because they are so 
directed by God. The sleep also is much disturbed, both 
by anxiety and distressing dreams. The pupils are occa- 
sionally dilated. The tendon reflexes may be exaggerated, 
and vasomotor disturbances may be present. The skin 
loses its normal healthy appearance, becoming dry and 
flaccid. The menses cease or become irregular. Later in 
the course of the disease the appetite returns and often 
becomes excessive. At this time the weight often rises 
rapidly, and the emaciated condition is frequently replaced 
by great corpulence. The menses also reappear and remain 


normal, and the evidences of muscular and nervous irrita- 
bility disappear. 

Course. — The course of disease in this form is progres- 
sive, leading to characteristic states of mental deterioration 
of different grades, except in a very small percentage of 
cases. The course is marked by short periods during 
which the patients show great motor restlessness, irrita- 
bility, sexual excitement, silly aggressiveness, and great 
show of emotion; there may be a clouding of conscious- 
ness with great impulsiveness, increased incoherence of 
thought, singing, dancing, and insubordination. These 
states of deterioration are usually reached within two 
years of the onset. In some cases, where the development 
of the disease has been very rapid, the deterioration ap- 
pears in six months ; in other cases it may not be evident 
for a few years. The degree of mental defect increases 
from year to year, more especially following the transitory 
periods of excitement. 

Of the cases that are admitted to insane institutions, 
about seventy-five per cent, reach a profound degree of de- 
terioration. These patients are dull, indolent, apathetic, 
anergic, sluggish, and fail to apprehend the surroundings. 
They remain seated for hours wherever placed, are incap- 
able of caring for themselves, are untidy, have to be 
dressed and undressed, and led to meals. At table they 
are slovenly, spattering and smearing themselves with 
food. They give but little evidence of voluntary activity. 
They seldom speak, are unproductive and mute ; occasion- 
ally they may be seen to laugh sillily or repeat to them- 
selves some unintelligible word or syllable. 

Their attention is attracted with difficulty and held 
only for a short time. External objects usually fail to 
make an impression upon them. Questions are apparently 


uncomprehended, seldom exciting intelligible answers. 
These are usually monosyllabic and irrelevant. Simple 
directions, however, may be correctly carried out. Rela- 
tives and acquaintances may not be recognized. Bits of 
former knowledge are retained in many cases for a long 
time, such as historical and geographical facts and the 
ability to solve problems in arithmetic. In this respect 
the patient often surprises one. One of my patients was 
able to name the islands of the Pacific and give the names 
of their sovereignties. Another, who for two years had 
been mute, unable to care for himself, untidy, sitting 
through the day with bowed head, entirely unmindful of 
his surroundings, recognized a college mate, straightened 
up with an air of dignity, and laughed at some college 
jokes. In the course of time even such relics of former 
mental activity disappear, and we have nothing left but 
the unproductive vegetative organism. A few patients 
retain some remnants of mental activity, but they are 
quite unbalanced, silly, and present the residuals of hallu- 
cinations and delusions. Instead of the extreme stupidity 
and indolence some patients continue restless and talkative, 
producing an incoherent babble with silly laughter. Dur- 
ing the periods of transitory excitement these patients 
are very apt to be aggressive, breaking windows and 
attacking fellow-patients, to masturbate shamelessly, pull 
out their hair, and frequently show homicidal tendencies. 
In about seventeen per cent, of the cases the degree of 
deterioration is not as far advanced. These patients, after 
the subsidence of the more acute symptoms, show a cer- 
tain amount of mental activity and are capable of some 
employment under supervision. They are oriented and 
have a certain amount of insight into their mental inca- 
pacity, but lack mental energy and the power of applica- 


tion. They have little interest in the surroundings, no 
care for their own livelihood, and no thought for the future, 
but are contented to live and be cared for. In conduct 
they are apt to present many mannerisms. 

The judgment is weak and memory defective. Impor- 
tant events may be retained, together with school knowl- 
edge, but memory for events subsequent to the onset of 
the psychosis is very poor, while they are quite incapable 
of acquiring additional knowledge. The hallucinations 
and delusions of the various stages of the disease for the 
most part entirely disappear. While retained in a few 
cases, they are of little importance to the patients, rarely 
influencing their behavior. As in the other grades of 
dementia, so here, there is a tendency for the deterioration 
to increase as the patients advance in age. This is espe- 
cially noticeable following short periods of excitement, 
which are apt to be coincident with menstruation. At 
these times the patients show motor restlessness, with 
great irritability and sometimes violence, with a reappear- 
ance of former delusions and hallucinations, talkativeness, 
silly behavior, and incapacity for employment. The delu- 
sions are more apt to be expansive, changeable and inco- 
herent, but at times there may be verbigeration and 
repetition of single phrases. The actions are usually 

A few cases leave the institution apparently recovered, 
but upon reaching home the patients fail to employ them- 
selves profitably. They spend much time in reading, 
evolving impractical schemes, pondering over abstract 
and useless questions. Or, if employed they show a lack 
of interest, are unbalanced, and unable to advance in their 
profession or occupation. Later their field of thought 
becomes more circumscribed and their relations with the 


outside world correspondingly meagre. They become 
seclusive and so much disinterested in intellectual work 
that they pass their time in purely machine-like action, 
engaged in gardening or transcribing. 

Finally in about eight per cent, of the eases the symp- 
toms of the disease entirely disappear, leaving the patients 
apparently in their normal condition. Not all of these 
cases should be regarded as perfect recoveries, because 
in some instances there have been recurrences in later 
life, followed by deterioration. In still other cases there 
has been a stunting of mental development. The patients 
have been unable to realize their ambition. Young men 
and women whose academic or collegiate courses have been 
interrupted by the psychosis find themselves unable to 
enter into active business or professional life. These 
patients are able to care for a farm or a small business 
where there is little demand for intellectual work. In 
this way we lose sight of the mental shipwreck follow- 
ing dementia prsecox, because enough mental capacity is 
retained to permit them to maintain the battle of life 
in their chosen narrow field. 


The catatonic symptom-complex, first described by 
Kahlbaum in 1874, and which by several psychiatrists is 
regarded as a separate disease process, is by us considered 
a form of dementia praecox. 

This form is characterized by a peculiar condition of 
stupor, with negativism, automatism, and muscular ten- 
sion ; excitement with stereotypy, verbigerations, and echo- 
lalia, leading in- most cases, with or without remissions, 
to a condition of mental deterioration. 

There has been no special pathological basis discovered 
for this symptom-complex. Alzheimer has described cases 
running the fatal course of an acute delirium, which he 
believed belonged to catatonia. In these he found pro- 
found changes in the cortical neurones of the deeper 
layers. The nucleus was much swollen, its membrane 
wrinkled, and the cell body shrunken, with a tendency to 
disappear. In the glia there was an increase of fibres 
which fastened about the cell in a peculiar manner. 
Nissl, later in the disease process, has demonstrated exten- 
sive changes in the cortical neurones, which he designates 
as granular degeneration. Even in cases where there 
appeared to be no atrophy in the cortex, he found a 
number of cells which had undergone degeneration. In 
the deeper layers of the cortex very large glia cells were 
found which normally appear only in the outer layer. 
Elsewhere the cortex contained glia cells which were in 



close approximation to the degenerated nerve cells, and 
not only at the base of the cell body, like the satellite 
cells, but also around it. 

The onset of the psychosis is usually subacute, with 
a condition of mental depression. The patients for 
several weeks before the onset may have appeared 
unusually quiet, serious, or even anxious, complaining 
of difficulty of thought, of headache, or of peculiar sen- 
sations in the head. Besides this, they may have 
suffered from insomnia and loss of appetite, and have 
left their work because of nervousness and general 
ill health. Gradually the patients show great anxiety, 
and express fear of impending danger. Their religious 
emotions become more prominent, and hallucinations and 
delusions appear. A voice from heaven directs them to 
do all sorts of things. One patient is commanded to spit 
to the right, and another to convert sinners. There is a 
vision of Christ on the cross, the Virgin Mary appears, 
faces are seen at the window and pictures on the wall, 
spirits hover about, some one speaks from the radiator, 
and there is music in the next room. He hears his chil- 
dren cry for help. Some one calls his name, and he hears 
his own thoughts. Little birds speak to him. Specks of 
poison are detected in the food, sulphur fumes are set free 
about him, some one pulls at his hair, injects water into 
his limbs, or applies electricity to him. 

The delusions are usually of a religious nature, are inco- 
herent and changeable from day to day. The patient is 
persecuted for his sins, a priest has come to anoint him 
before he dies. God has transferred him to heaven, where 
he is surrounded by angels. He no longer needs food, as 
Christ has forbidden him to eat. He is eternally lost, is 
possessed of the devil, has caused destruction of the whole 


world; all are dead, he is surrounded by spirits, battles 
are being fought outside, his children are lost, the wife 
false, his body has been transformed, his head replaced by 
that of a horse, his feet transformed into mules' hoofs, 
his hands into claws, his brain has been drawn off, and 
while hung to a cross, his limbs and body have run away 
like molten metal. The delusions usually become expan- 
sive later, though they are occasionally expansive from 
the onset. The patient then believes himself transformed 
into Christ, has all power, can create worlds, has lived 
for thousands of years, has waged many wars, possesses 
all knowledge, can instruct physicians in medicine, 
can cast out evil spirits, has pleaded in the highest 
courts, is a millionaire, and possesses railroads, ocean 
steamers, etc. 

During the earlier stages of the disease some peculiari- 
ties of movement and action appear, of which constraint 
is the most prominent. This may increase to a state of 
muscular tension. The patients assume constrained atti- 
tudes, holding the arms in awkward positions, as in the 
form of a cross, etc., standing or walking in an awkward 
manner, all of which may be symbolical of their ideas. 
One patient stood for hours with hands behind him and 
head thrown back, staring fixedly at the ceiling, and 
another lay in the form of a cross upon the floor. In 
some there is a tendency to execute rhythmical move- 
ments, such as rolling the head from side to side, or ex- 
pectorating at stated intervals in a fixed direction. 

In this period of depression the consciousness is some- 
what clouded, orientation is slightly disturbed, and the 
patients do not apprehend clearly what goes on about 
them. They may know that they are at home or in an 
institution, but they fail to appreciate the mental condi- 


tion of their fellow-patients, mistake those about them 
for friends and acquaintances, or they claim that every- 
thing is changed and that they cannot understand the 
mysterious occurrences. Some believe themselves trans- 
lated to heaven, that they are in a cloister or in a foreign 

Thought is much disturbed, being incoherent and dis- 
connected. The patients are quite unable to reason. 
When questioned about their ideas they make all sorts of 
contradictory and irrelevant remarks. The memory, on 
the other hand, is good except for events since the onset 
of the psychosis. The attention can be maintained only 
for short periods. 

The emotional attitude is at first quite in accord with 
the delusions and hallucinations. The patients are 
sad, dejected, anxious, complaining, irritable, distrustful, 
and sometimes threatening; when interfered with, they 
are very apt to become violent. Occasionally sexual 
excitement leads to masturbation and obscenity. Later 
they lose their early anxiety, become indifferent or con- 
tented with their environment, and the delusions are 
expressed without emotion. Some patients are even 
cheerful and happy, or ecstatic. 

Following this period of depression the more character- 
istic catatonic symptoms appear, namely: the catatonic 
stupor and the catatonic excitement. In at least one-third 
of the cases these symptoms appear at the very onset of 
the disease without the prodromal period of depression. 

The symptom most characteristic of the catatonic 
stupor is negativism. In negativism the voluntary im- 
pulses seem to be overcome by counter impulses. The 
patients may begin an act readily, but immediately 
a counter impulse checks and finally overcomes the for- 

Plate 1. Muscular tension in catatonic stupor, producing " Snautzkrampf." 


mer, producing an action contrary to the desired one. 
These adverse impulses may suddenly disappear, when the 
actions of the patient again become perfectly free. Nega- 
tivism usually occurs first as mutism, when the patients 
refuse to speak. They begin by speaking low, breaking 
off in the midst of a sentence or answering in monosylla- 
bles, then they may whisper unintelligibly, and finally 
refuse to speak altogether. Some patients in this condi- 
tion may be persuaded to write or sing answers to ques- 
tions. When addressed they remain with closed eyes or 
staring fixedly at some distant object, apparently paying 
absolutely no attention to the physician. Even shaking 
patients, pinching them, or prodding them with a needle 
fails to elicit a response, except when in pain, then the 
lips may become more closely pressed together or the 
patients may move away indifferently. 

Further evidence of negativism is seen in the obstinate 
and persistent resistance which the patients make to every 
attempt at handling them. They resist being put to bed 
and being taken out, dressing or undressing, moving for- 
ward or backward, opening the eyes or closing them. 
The active resistance is well demonstrated by suddenly 
withdrawing the hand which has been placed against the 
patient's forehead, when it springs forward with a jerk. 
The physical origin of this resistance becomes more appar- 
ent in those cases in which the desired action is only 
elicited by commanding the patient contra wise. One 
may get a patient to open his eyes by urging him to close 
them tightly, to lower the hand by telling him to lift 
it, etc. 

Even the most natural impulses are resisted, as seen 
in their stubborn refusal to wear shoes or stockings, in 
the tendency to sit on the floor rather than in a chair, 


or to sleep under the bed and not in it, and go to the 
closet by the longest route. They prefer to eat another's 
food, and some persist in crawling into the beds of others. 
Finally the refusal of food and the retention of urine 
and feces are evidences of more extreme negativism. 
The former may last for months. The absence of food 
for a week will not overcome this disinclination to take 
food voluntarily. It is not unusual for this form of 
negativism, as well as the others, to appear and disappear 
suddenly. Sometimes the patients will begin to eat if 
transferred to another building or to speak if placed in 
another ward, or will remain in bed if given a different 
bed. The urine and feces may be retained until there 
is marked distention. In a few cases it is necessary to 
overcome this by catheterization and enemata. This 
may be partially accounted for by the condition of muscu- 
lar tension, which is usually associated with negativism. 
The muscular tension, though exhibited in several ways, 
is most marked in the extraordinary uniformity of position 
maintained by the body or its various parts. In this 
condition patients maintain the same position for weeks 
and even months. The usual position is on the back with 
limbs stretched out, the eyelids closed with the eyeballs 
rolled upward and inward, or with the eyes open, staring 
fixedly in the distance, the face mask-like with lips 
slightly closed and at the same time protruded, producing 
what the Germans call Snautzkrampf. The hands are 
very often clenched, as if there were permanent contrac- 
tures, the fingers producing pressure marks on the palms. 
Plates 1 and 2 represent two stuporous catatonic patients. 
The boy rigidly maintained this uncomfortable position for 
weeks, with his head thrown far backward, eyes tightly 
closed, and face mask-like with protruded lips. While in 

Plate 2. Muscular tension in catatonic stupor. 


this condition he required daily feeding by nasal tube. 
The woman has maintained this same position for over 
two years without a known voluntary attempt to change 
it. The body and head are slightly bent forward with 
the eyes staring directly in front of her, the lips pro- 
truded, the arms flexed, and hands so tightly clenched that 
cotton must be placed in the fists to prevent pressure 
sores. While in bed she lies straight upon the back with 
knees strongly adducted, and arms drawn closely to the 
chest, but with the fists in the same constrained position. 
During this long period it has been necessary to feed her 
by spoon. Others lie rolled up like a ball, with head 
thrown forward and knees drawn to the chin. In the 
extreme condition these patients may be rolled about or 
lifted and laid across some object without movement, as 
rigid as a piece of wood. 

Where muscular tension is less pronounced, the limbs 
may be moulded into any position, which condition is 
called "cerea flexibilitas. ,, Plate 3 illustrates this form 
of muscular tension. This patient has been moulded into 
this awkward and very uncomfortable position, which she 
maintained until relieved. The feet are separated, drawn 
backward and elevated so that the toes barely touch the 
floor ; the arms are elevated and drawn backward, and the 
head is extended as far as possible. Muscular tension is 
not evenly distributed, but is most frequently seen in the 
hands, arms, face, and lower limbs. The gait is often 
influenced by this condition, some patients being unable 
to move at all, falling rigidly to the floor when raised to 
their feet; others walk stiffly, with unbent knees, on 
tiptoes, or on the outer side of the feet with the body bent 
forward or backward. The movements are usually slow 
and constrained. Sometimes the counter impulses seem 


to be suddenly overcome and the movements become 

A condition which seems to be directly the opposite of 
negativism is occasionally met during the stupor. Instead 
of increased resistance to every impulse, there is greater 
susceptibility to suggestion, producing echolalia and ecJio- 
praxia. The patients repeat quite mechanically that 
which is said to them or done before them. Questions 
asked are only repeated, the songs of another are sung 
over after them, and the actions of another patient or of 
the physician are repeated, such as limping or offering the 
hand to be shaken, and rolling the head about after the 
stereotyped fashion of another patient. 

These opposite states pass directly from one to another 
during the stage of stupor. Absolute silence suddenly 
gives way to loud and unrestrained shouting or to inces- 
sant prattle, the patients awake from the stupor and talk 
as if nothing had happened, and again in a few hours 
relapse into their former stuporous state. 

Interrupting the stupor or following it, and sometimes 
even preceding it, we have the catatonic excitement, which 
is characterized by impulsive actions and stereotyped move- 
ments. The condition of excitement usually makes its 
appearance rapidly. The patients suddenly leap from 
bed, tear their clothing, break the furniture, race about 
the room, shouting or singing, throw themselves upon 
the floor, rotating the head from side to side, breathing 
rapidly, churning saliva in the mouth, making a peculiar 
blowing sound, or rotating and pronating the forearm. 
They may run about the house for hours at a time, strik- 
ing the bed or the wall in a certain place. While lying 
in bed the body may be swayed regularly back and forth, 
or the bed tapped at a certain place at regular intervals. 

Plate 3. Cerea flexibilitas in catatonic stupor 


In walking they are apt to assume peculiar attitudes. 
One patient stood for hours against the wall in the form 
of a cross repeating, " the Father, the Son and the Holy- 
Ghost/ ' another holding his nose tightly with his hands 
uttered a monotonous grunt for hours at a time. These 
movements may be less constrained and regular when the 
patients jump about from one object to another, pounding 
themselves, knocking their heads against the wall, wring- 
ing their hands, jumping up and down on the bed and 
stamping on the floor. All of these most varied move- 
ments are carried out with great strength and reckless- 
ness, without regard for the surroundings or themselves, 
and are for the most part purposeless and impulsive. 
In the midst of their ceaseless tramping about the room 
they may suddenly grab at the clothing of the physician 
or assault a fellow-patient. During this excitement the 
patients are very untidy and filthy, expectorating in the 
food, smearing with feces and food, urinating in the bed 
and clothing, and even washing themselves with the urine. 
Sexual excitement very often accompanies this condition. 
Another prominent symptom of this stage of the dis- 
ease is the mannerisms in facial expression and speech. 
Accompanying speech there is a peculiar gesticulation, 
winking of the eyes, senseless shaking and nodding 
of the head, and drawing of the muscles of expression. 
The voice assumes a peculiar intonation or may quiver. 
The manner of speech may be scanning, rhythmical, or 
explosive. The content of speech is often quite charac- 
teristic, consisting of a series of senseless syllables 
repeated in a fixed measure or rhyme. Words or short 
sentences are likewise repeated; the words may be 
clipped or the last syllable drawn out. Usually these 
expressions bear no relation to the trend of conversation. 



One patient, when asked how he felt, repeated for three 
minutes, " I see you, I see you." The formation of new 
words often accompanies the senseless repetition of sylla- 
bles, making a childish babble which the patients may 
repeat for hours. Verbigeration is especially noticeable 
in the letters. The excessive underlining, shading, and 
addition of symbols are clearly manifestations of the 
tendency to mannerisms. The accompanying illustra- 
tion is a sample of the writing of a catatonic patient, 
representing an envelope addressed to her physician. 

^ ^^ ^t^T^p^f. 

Fig. 1. Catatonic Writing. 

The conditions of catatonic stupor and catatonic excite- 
ment succeed each other during the entire course of the 
disease, and often quite suddenly. The degree of stupor 
and excitement varies considerably in individual cases. 

As in the depressive stage, so also during the catatonic 


stupor and excitement, the consciousness is somewhat 
clouded, but the patients seldom lose their orientation 
completely. In spite of the fact that they seem quite 
unconscious of and unable to comprehend their surround- 
ings, the patients awake from this condition and give 
the names of those about them, telling the day and the 
month, and showing surprising knowledge of what has 
happened within their limited range of observation. 

At first there is occasionally some insight into the 
mental disturbance, the patient remarking during the 
depression that his head is not right, and later, during 
the excitement, that many of his constrained and peculiar 
acts are foolish, but that he cannot help doing them. 
Others explain them by saying that they are commanded 
to do so by God. On the other hand patients are quite 
unable to appreciate the necessity for their confinement or 
for the care of a physician. The emotional attitude after 
the marked dejection at the onset is quite in accord with 
the delusions. Occasionally there is noticed childish petu- 
lancy or irritability. 

Physical Symptoms. — In some cases elevated tempera- 
ture varying between one hundred and one hundred and 
two degrees during the acute onset of the symptoms may 
persist for two or more weeks. There are very apt to be 
vasomotor disturbances, appearing as cyanosis, dermo- 
graphia, and localized sweating. Convulsive attacks are 
also encountered in a few cases, mostly during the onset. 
There is loss of weight during the stage of depression. 
This becomes more prominent during the stupor and may 
reach a stage of extreme emaciation in spite of forced 
feeding. Later, sometimes beginning during stupor, 
the weight rises. During the stage of deterioration the 
patients usually become quite fleshy. During stupor the 


skin is cold and clammy, the heart's action slow and feeble 
and the bowels constipated. 

Course. — The usual course in the catatonic form is 
depression, followed by excitement, passing into deteriora- 
tion. In a few cases the stupor is immediately followed 
by dementia without the intervention of the characteristic 
excitement. Occasionally the excitement precedes the stu- 
por and may even appear at the very onset of the disease. 

A prominent feature in the course of the disease, which 
rarely appears in other forms of dementia praecox, is the 
remissions. Remissions for a few days or a few hours 
occur in almost all of the cases. The consciousness of 
the patient becomes perfectly clear, they apprehend and 
remember events, are quiet and rational and often express 
a feeling of illness. At these times close observation dis- 
closes a certain restraint in manner and actions, a dis- 
torted emotional attitude, and a lack of full appreciation 
of their previous condition. In at least one-third of all 
the cases the remissions are long enough for the patients 
to seem to have completely recovered. It may last from 
five to fifteen years. In these cases one often detects cer- 
tain peculiarities, indicating that recovery is not complete, 
such as irritability, seclusiveness, and forced, affected or 
constrained manners. These remissions more frequently 
appear after stupor and are followed by excitement. 

The outcome in eighty-six per cent, of the cases is ulti- 
mately mental deterioration, which in thirty-nine per cent, 
becomes extreme. In these cases usually within two years 
the stupor and excitement disappear and the hallucinations 
and delusions become less prominent, but the patients 
remain sluggish and indifferent, without mental energy. 
They are able to comprehend simple questions,' but they 
lack mental initiative. The memory is defective, the 


judgment poor, and they are unable to acquire new knowl- 
edge. They have no regard for themselves, their personal 
appearance, or their future. They remain contented where- 
ever they happen to be, never expressing desires. They 
are wholly unfit for intellectual employment, as they have 
no idea of how to work. Upon questioning, and volun- 
tarily in a few cases, delusions and hallucinations are 
expressed; the former are usually expansive but quite 
incoherent and without effect upon the bearing of the 

Some of the patients are very inactive, remaining stu- 
pidly in one place most of the time, sometimes muttering 
to themselves, but taking no interest in their surround- 
ings. Other patients are active, restless, and unbalanced. 
In both of these groups, and especially in the latter, we 
find mannerisms which are the residuals of former stere- 
otypy. The movements lack freedom, are constrained 
and peculiar; the patients walk on tiptoe, along cracks, 
or with bent limbs, with head thrown forward and with 
cramped hands. The head is usually held in peculiar 
positions. When sitting they always assume fixed posi- 
tions, shaking or nodding the head at regular intervals, 
making a blowing noise with the lips or grunting. They 
pass to meals only through certain doors, or perhaps back- 
wards. The mannerisms are especially marked in dressing 
and at table. 

They may eat with great rapidity, filling the mouth to 
its fullest extent before swallowing. Others eat very de- 
liberately, waiting a certain interval between mouthfuls, 
perhaps counting three, each bit of food being prepared 
and carried to the mouth in a certain definite manner. 
Many patients eat with their hands, others hold the knife 
and fork in some peculiar fashion. One of my patients 


refused to eat unless he had been allowed to stand on his 
head and crawl under the table. Similar mannerisms are 
evident in speech and writing. In speech there may also 
be a tendency to form new words, especially during the 
transitory periods of excitement, when the patients pro- 
duce a genuine word-jumble. 

The deterioration gradually deepens, and especially fol- 
lowing short periods of excitement, which appear in al- 
most all cases. At these times the patients are restless, 
irritable, and threatening, expressing delusions of persecu- 
tion ; in speech the confusion becomes marked, with shout- 
ing and laughing. There is a great tendency to perform 
impulsive acts, breaking furniture, attacking individuals, 
and even becoming homicidal. 

In twenty-seven per cent, of the cases the dementia is of a 
lighter grade. Here the patients return to clear conscious- 
ness, are quiet and orderly, are able to return home, and 
in a few cases resume their former occupations. But a 
profound change in the character is noticed ; their former 
mental vigor does not return, they are listless, dull, lack 
energy and endurance. Their judgment is defective. 
They are cleanly and except for a few catatonic manner- 
isms might be regarded as well. Some of these patients 
are very quiet, seclusive, distrustful, or over-conscientious ; 
while others are somewhat childish and silly. 

In about thirteen per cent, of the cases patients seem to re- 
cover. Some of these patients manifest some peculiarities in 
conduct and a change in character which is apparent only 
to those associated closely with them. A certain number of 
these cases after five to fifteen years suffer from another 
attack which leads to deterioration. 

As yet there are no means of judging which cases will 
recover, have long remissions, or lead to different degrees 


of deterioration. This much can be said, however, that 
those with rapid and more acute development are more 
apt to have a remission than those with a gradual onset. 
Clearing of consciousness without proportionate improve- 
ment in the emotional attitude, with persistence of man- 
nerisms and the appearance of short periods of excitement, 
point to deterioration. The mere presence of prolonged 
stupor does not necessarily indicate deterioration, as pa- 
tients have remained in stupor from three to five years. 
The fatal termination of the catatonic form usually 
occurs as the result of some intercurrent disease, of which 
tuberculosis is the most prominent. The special predispo- 
sitions for this disease are shallow respiration, inactivity, 
and untidy habits. 


Kahlbaum, Die Katatonie oder des Spaimungsirresein, 1874. 

Behr, Die Trage die Katatonie oder des Irreseins nur Spannung. 

Diss. Dorpat, 1881. 

Schule, Allgem. Zeitschr. f. Psychiatrie, Bd. 54, S. 515. 

Aschaffenburg, ibid., S. 1004. 

Tschisch., Monatschrif t f . Psychiatrie und Neurologie, Bd. 6, S. 241. 


The paranoid forms of dementia praecox, which include 
two groups of cases, are characterized by the great promi- 
nence and persistence of delusions and hallucinations for 
several years, in spite of progressing mental deterioration. 
While there are many delusions and hallucinations in the 
hebephrenic and catatonic forms of dementia praecox, 
they are never very prominent and usually disappear as 
deterioration progresses. The cases grouped under this 
term are by many psychiatrists considered as forms of 
paranoia, a view which in our minds is untenable, because 
of the comparatively rapid appearance of mental deteriora- 
tion, and also because of the occasional acute onset and 
the frequent occurrence of single catatonic symptoms, 
such as stuporous states, mannerisms, and neologisms. 

The First Group of cases is characterized by many in- 
coherent and ever changing delusions of persecution and 
grandeur, and a light grade of motor excitement, with 
retention of clear consciousness for a considerable time 
and rapid appearance of mental deterioration. 

The onset of the disease is gradual, following a period 
of headache, malaise, and insomnia with a rapid loss of 
energy and often irritability. The patients act peculiarly, 
are unusually devout, seem depressed and anxious, and 
remain alone. In a short time they divulge a host of 
delusions, almost entirely of persecution ; people are 
watching them, intriguing against them, they are not 
wanted at home, former friends are talking about them 
and trying to injure their reputation. These delusions 



aro changeable and soon become fantastic. The patients 
claim that some extreme punishment has been inflicted 
upon them, they have been shot down into the earth, 
have been transformed into spirits and must undergo all 
sorts of torture. Their intestines have been removed by 
enemies and are being replaced a little at a time ; their 
own heads have been removed, their throats occluded and 
the blood no longer circulates. They are transformed 
into stones, their countenances completely altered, they 
cannot talk, eat, or walk like other men, etc. Hallu- 
cinations, especially of hearing, are very prominent during 
this stage ; fellow-men jeer at them, call them bastards, 
threaten them, accuse them of awful crimes. Messages 
over the telephone are overheard mentioning that they 
are about to be sent to prison. Occasionally faces and 
forms are seen at night, or a crowd of men throwing 
stones at the window. Foul vapors may be thrown into 
their bedding. Patients during this time are anxious, 
agitated, restless, and emotional. They mistrust the 
surroundings, at times becoming aggressive and violent. 
In a paroxysm of fear they may even attempt suicide. 

The consciousness usually remains unclouded. The 
emotional attitude before long loses the sad and anxious 
tinge, being replaced by a certain cheerfulness and exalta- 
tion. At the same time the delusions become less de- 
pressive and more expansive and fantastic. The patient 
in spite of persecution is happy and contented, extravagant 
and talkative, and boasts that he has been transformed 
into the Christ ; a female is pregnant by the Holy Ghost ; 
others will ascend to heaven, have lived many lives, have 
visited other worlds, and have journeyed over the whole 
universe. They have the talent of poets, can surpass 
famous war correspondents, have been nominated for 


president, and have represented governments at foreign 
courts. These delusions may become most florid, foolish, 
and ridiculous. A patient will say that he is a star, that 
all light and darkness emanate from him; he possesses 
all knowledge, is an artist, the greatest inventor ever 
born, can create mountains, is endowed with all the at- 
tributes of God, can prophesy for coming ages, can talk to 
the people in Mars ; indeed, is unlike anything that has 
ever existed. 

Associated with these variegated and ever changing 
expansive delusions are delusions of persecution, almost as 
absurd and extreme, but expressed without corresponding 
emotion. While laughing they may complain that they 
have been deprived of their limbs, are wrecks of a dread- 
ful struggle with enemies, having been pierced with thou- 
sands of bullets and been thrown into hell, where they 
were exposed to furnace flames. Suggestions for many of 
these delusions may arise from pictures on the wall or 
from reading. 

These patients are usually talkative, expressing freely 
their many delusions. Some of them fill hundreds of 
sheets of paper trying to describe them. At first they are 
quite coherent, but later there is such a wealth of ideas 
loosely expressed that it is difficult to find any system in 
them. They wander aimlessly about from one delusion 
to another, showing frequent repetitions of the same 
ideas. Questions, however, are answered in a coherent 
and relevant manner. Later in the course of the disease 
the speech becomes more and more difficult of comprehen- 
sion, because of the number of peculiar phrases and ex- 
pressions to which they attach special significance and 
freely repeat. The writings likewise become more and 
more unintelligible. 


The patients rarely possess insight into their condition. 
The consciousness becomes somewhat clouded later in the 
disease. Orientation as to place is least disturbed, but 
people are soon mistaken, often designated as celebrated 
personages, and all conception of time is lost. They recog- 
nize relatives, and can give a fairly clear statement as to 
where they are. They may recall some past knowledge, 
but they soon become unable to use it in reasoning. 
They cannot apply themselves to any mental work. The 
patients show an exaltation of the ego with heightened 
feelings, they are self-conscious, with an important bearing, 
and demand special attention. In emotional attitude they 
are almost always exalted, rarely depressed, although a few 
patients show restlessness, some irritability and occasionally 
some passion, often in connection with the menses. Many 
of the patients are able to. perform some mechanical work, 
but need supervision because of their lack of application. 

Physical Symptoms. — There is very little physical dis- 
turbance except the loss of weight and insomnia at the 
onset, with interference of nutrition. 

The course is progressive without remissions. The signs 
of mental deterioration may appear within a few months, 
and are usually well marked by the end of two years. 

The patients may for a long time retain clear conscious- 
ness and partial orientation, but the content of thought 
become thoroughly incoherent and there is a lack of energy 
and plan in their activity, which incapacitates them for all 
mental application. While active and somewhat interested 
in their environment, they still display a self-conscious 

The Second Group of paranoid cases is characterized by 
hallucinations and fantastic delusions of persecution and of 
grandeur, which are mostly coherent, and are adhered 


to for a number of years, when they disappear, leaving 
the patient in a state of moderate deterioration. 

The first symptoms to appear are those of despondency 
with some self-accusation. The patients are troubled with 
thoughts of death and religious doubts; they are unusually 
devout, and seek religious advice. They fear that they 
have done wrong, have committed some crime, or are 
suffering the penalty of self -abuse. Coherent delusions of 
persecution develop gradually; people watch them, pecul- 
iar actions are noticed, acquaintances are less friendly, 
and children on the street jeer and laugh at them, per- 
haps mimicking their manners. Passers on the street 
who are entirely unknown to them turn and stare. In 
public places, in the cars and at the church, remarks are 
made which refer to them. They are libeled in news- 
papers. All these incidents have a hidden meaning, which, 
however, is fully understood by the patients. They are 
making their own observations and will be ready to expose 
the offenders and bring them to justice at the proper time. 
Affairs at home are unsatisfactory : the children are differ- 
ent, and the husband or wife is unfaithful. 

Hallucinations, especially of hearing, rarely of sight, are 
prominent at this time, aiding in the elaboration of the 
delusions. Enemies take advantage of their confinement 
by standing below the window calling them all sorts of 
names, announcing that they are to be imprisoned, that 
they have committed murder, and are to be put to the 
rack. Voices are heard from the walls and from under 
the floor stating that they are wretches and outcasts of 
society. Very often the noises really heard, such as the 
blowing of whistles and the ringing of bells, are mis- 
interpreted in accord with their delusions. They com- 
plain that the food contains poison which they can taste, 


they suspect phosphorus in the tea and detect kerosene on 
the clothing. 

They notice that their clothing is changed, butr 
tons are missing, there is a rip in the coat and a pocket 
torn. Objects in their surroundings are changed in order 
to confuse them. Many somatic sensations, such as 
twitching of individual muscles, headache, specks before 
the eyes, pain about the heart, and cramp in the bowels, 
are all evidences of injuries caused by their enemies. The 
explanation of these somatic hallucinations often takes 
fantastic forms. An itching of the foot is sufficient 
evidence that a poisonous powder has been blown into 
their shoes, pain in the back indicates that they have been 
shot there while asleep, a frontal headache is the result of 
poisonous vapors, which are set free in the room at night 
in order to destroy their intellect. A tremor of the fingers 
is produced by means of electric currents sent through the 
air. Something is placed in their food to create sexual 

The means employed by the persecutors for producing 
physical discomfort are varied. All known agencies are 
mentioned, as, magnetism, hypnotism, X-rays, telepathy, 
and electricity. These are accountable for the most 
various sensations in all parts of the body. They are 
compelled to act contrary to their own will and to say 
distasteful things. Organs of the body are removed and 
then replaced out of order, and the intestines are shrunken. 
It is quite characteristic for the patients to refer to these 
physical changes by some invented names, such as, ugly 
duberty, snicking, lobster cracking, etc. Others complain 
that their minds are influenced, their thoughts are gone, 
they have no control over their thoughts, which in spite 
of themselves are always evil. They attribute the origin 


of such thoughts to others which are forced upon them 
in spite of themselves. 

Ideas of spirit-possession are often a prominent feature. 
Here the enemy enters and takes possession of the body, 
causing the bones to crack and the head to rattle ; obscene 
remarks proceed from the stomach ; their ears are filled by 
all sorts of noises made by these spirit-possessors. They 
cause the testicles to fall and the throat to dry up. 

Expansive delusions are also present in almost all cases. 
These are as variegated and fantastic as those of persecu- 
tion. The patients have been awarded a crown for 
bravery and now rule over some country, possess beauti- 
ful dresses, and are betrothed to the king. They repre- 
sent the Pope and are to travel all over the world. God 
daily appears to them and gives them a blessing. They 
have recently been entrusted with millions which they 
are to invest in mining. They have consummated im- 
mense trusts which they are to manage. All of the 
many delusions expressed by the patients are at first 
coherent, and show a tendency to some course of reason- 
ing, but after a few years they become quite incoherent. 

The consciousness during the development of these delu- 
sions, and for a long time afterward, perhaps years, 
remains clear. The patients are oriented. Thought is 
coherent, but centres about the delusions. The patients 
are able at first to offer some basis for the delusions and 
to refute objections, but later, as deterioration appears 
gradually in the course of several years, thought becomes 
cloudy and confused. Then the delusions are incoherent, 
contradictory, and unstable, and change rapidly. There 
is rarely insight into the disease. Many patients appre- 
ciate that they are not normal, but their defects and ail- 
ments are all regarded as the works of their persecutors. 


The emotional attitude is at first characterized by depres- 
sion and anxiety, but later this gives way to a certain 
amount of happiness and cheerfulness, with considerable 

In conduct and manners the patients may at first be 
quite orderly; but later, in accord with their delusions, 
they are suspicious, journeying about to get rid of their 
enemies, applying to police for protection ; or, taking the 
matter in their own hands, they attack supposed perse- 
cutors or attempt to expose them through the papers. 
Others contrive a sort of armor for themselves, place 
metals in their shoes or wires in their clothing to divert 
the electrical currents. In accord with expansive delusions 
they may decorate themselves in fantastic costumes, adorn 
themselves with badges, assume a superior air, and use 
high-flown language. 

There are no definite physical symptoms. 

The course is slowly progressive to mental deterioration. 
However, one can discern certain stages. At first there is 
a change of disposition, then a prominence of delusions 
of persecution, later the appearance of the delusions of 
grandeur, indicating the onset of deterioration, and finally 
the fading away and entire collapse of the delusions. 
Remissions have occurred in a few cases. 

The outcome is always deterioration. The delusions in 
the course of several years cease to further develop and 
gradually fade away, leaving the patient with a certain 
degree of mental weakness, seen in lack of judgment, and 
absence of mental energy. Ideation is scanty. In con- 
versation the patients are incoherent and unintelligible, 
with occasional references to former delusions. In their 
actions they show many peculiarities, and a lack of appre- 
ciation of and conformity to external relations. They 


are usually capable of employment, and sometimes are 
even industrious, the former " Pope " becoming a trusted 
farm-hand, and the "queen" a good seamstress. Finally 
they reach a stage of apathetic deterioration, when they 
are incapable of any employment. 

Diagnosis of Dementia Praecox. — Acquired neurasthenia 
is distinguished from the hebephrenic form by the fact 
that the hypochondriacal ideas are not silly^ the judgment 
is retained, there is no evidence of deterioration, the 
patients are not stupid, and finally they improve with 
treatment. The presence of hallucinations is a positive 
sign of dementia praecox. 

The disease is distinguished from dementia paralytica 
by the early age of onset (fifteen to thirty), less rapid 
development of deterioration, especially in memory which 
in dementia paralytica is both rapid and profound, less loss 
of judgment, the retention of apprehension contrasted to 
the great stupidity and indifference of the paretic. Man- 
nerisms, mutism, negativism, and stereotypy may appear in 
dementia paralytica, but they are unstable and transitory. 
The contrariness and obstinacy of the paretic are usually 
unaccompanied by other signs of negativism, — refusal of 
food and mutism. If mutism and refusal of food are 
present, they are less obstinately carried out and are accom- 
panied by a more marked clouding of consciousness. The 
excitement in dementia paralytica, accompanied by stereo- 
typed movements, impulsive actions, etc., is distinguished 
from the catatonic excitement by the great disturbance of 
apprehension, attention, and thought. Finally the presence 
of physical signs speaks for dementia paralytica. 

It is differentiated from amentia by the absence, except 


in a very few cases, of the characteristic exciting cause, 
namely, nervous exhaustion; by the gradual onset, the 
uniform emotional attitude, contrasted with the rapidly 
changing emotional state in amentia, and by the less marked 
clouding of consciousness ; the patients are at least par- 
tially oriented, while in amentia there is complete dis- 
orientation. In amentia the patients do maintain attention 
to the surroundings, while in dementia praecox they are 
sluggish or indifferent in apprehending. In amentia the 
patients are at all times quite unable to carry on a con- 
versation, and talk incoherently of their past experiences. 
In dementia praecox, while at times they are monosyl- 
labic and entirely incoherent and silly, they occasionally 
surprise one by the recitation of knowledge of their 
earlier days. 

The greatest difficulty arises in distinguishing the de- 
pressive form of manic-depressive insanity from the period 
of depression which one meets at the onset of the hebe- 
phrenic and the catatonic forms. The early appearance 
of many hallucinations speaks for dementia praecox, as. 
well as an emotional attitude which does not correspond 
to the depressive character of the delusions. The patients 
remain quite indifferent during the visit or at the death 
of a relative, while in manic-depressive depression the 
feelings are apt to be intensified. The apparently similar 
conditions of negativism of the catatonic and of retarda- 
tion of the manic-depressive are at times distinguished 
only with difficulty. In the former there is uniform, rigid, 
and stubborn resistance to every passive movement, and 
if pain is produced by pricking, there is a simple with- 
drawal without effort at defence ; while in retardation the 
passive movements are permitted and painful contacts 
are resisted. Voluntary movements in the catatonic stupor 


are rare, but when executed are carried out without delay, 
and at times even rapidly, except when these movements 
are made by request, then there is always delay. In 
retardation all voluntary movements are carried out very 
slowly. There is sometimes a certain resistance due to 
apprehension and fear, but this is active. 

The excitement of the catatonic is to be distinguished 
from the excitement of the maniacal forms of manic- 
depressive insanity. In the catatonic form there is greater 
disturbance of conduct, the content of speech and emotional 
attitude, while in the maniac there is greater disturbance 
of apprehension, orientation, and thought. In the catatonic 
excitement the clouding of consciousness is less marked 
than in the maniacal excitement, the patients being par- 
tially oriented, even in the greatest excitement, while in 
the extreme maniacal state there is complete disorienta- 
tion. On the other hand the speech of the catatonic who 
has less motor excitement is more senseless and difficult 
to follow than that of the maniac who has extreme motor 
excitement. The catatonic speech abounds in verbigera- 
tions and stereotyped expressions and is free of comments 
upon the surroundings, while the speech of the maniac 
presents the characteristic flight of ideas, and is centred 
upon or drawn largely from the immediate surroundings. 
In this condition attention is readily distracted by the sur- 
roundings, while the attention of the catatonic cannot be. 
The attitude of the catatonic is silly, childish, exalted, or 
irritable. The movements of the catatonic are purposeless, 
frequently repeated, in contrast to the pressure of activity 
of the maniac in whom the movements are always purpose- 
ful with some relation to the surroundings, dependent 
upon ideas, impressions, and emotions, and always appear- 
ing in new forms. The increased activity of the catatonic 


is more apt to be limited to one corner of the room or of the 
bed, while that of the maniac is limited only by his confines. 

It is sometimes necessary to differentiate catatonic 
excitement with epileptiform or hysteroid attacks from 
hysterical states. In the latter one is usually able to 
detect slyness and method in the contrariness and pur- 
pose in the actions, while in the catatonic there is evident 
senselessness and lack of purpose in movements, and the 
emotional attitude exhibits more stupidity. Finally, 
hallucinations and delusions are more exaggerated and 
prominent in the catatonic. 

The distinction between the paranoid forms of dementia 
praecox and pure paranoia depends upon the lack of 
system, the rapid development of fantastic delusions com- 
mencing with prominent hallucinations ; while in paranoia 
the onset is very gradual, sometimes extending over one 
year with only a few hallucinations. The delusions in 
dementia praecox are extremely fantastic, changing beyond 
all reason, with an absence of system and a failure to 
harmonize them with events of their past life ; while in 
paranoia the delusions are largely confined to morbid 
interpretations of real events, are woven together into 
a coherent whole, gradually becoming extended to include 
even events of recent date, and contradictions and objec- 
tions are apprehended and explained. In emotional atti- 
tude the dementia prsecox patient soon shows clear and 
marked changes; — depression or silly elation, sexual ex- 
citement and remissions ; while in paranoia the emotional 
attitude is uniformly natural, the demeanor is almost 
normal, and the patients are capable of occupation for 
a long time. In paranoia there may be partial remissions 
when the patients react less actively to the delusions, but 
the delusions never disappear. 


In the absence of history of the early life and of the 
psychosis, imbecility may be confused with the end stages 
of dementia precox. The differentiation then depends 
upon the presence of transitory periods of excitement with 
impulsiveness, and the occasional expressions which give 
evidence of earlier school knowledge. 

The dreamy states of epileptic insanity are distinguished 
from the stupor of the catatonic form by the anxious 
resistance contrasted to negativism, and the presence of 
ecstatic attitude and a more profound disturbance of con- 
sciousness. The actions are prompted by feelings, while 
in the catatonic they are purposeless and stereotyped. 

The prognosis of dementia praecox is unfavorable, as 
the vast majority of cases end in mental deterioration. 
As already stated, this varies in the different forms ; thir- 
teen per cent, of the catatonics and eight per cent, of the 
hebephrenics recover, and none of the paranoid form. 
Even the few cases which seem to have recovered may 
suffer from another attack later in life, which leads to 
deterioration. The degree to which the mental impair- 
ment advances is sufficiently indicated in the discussion 
of the course of the disease in the different forms. 

Treatment. — Our meagre knowledge of the causes of 
the disease restricts the indications for treatment to the 
individual symptoms. Almost all cases, and especially 
those with the acute and sub-acute onset, demand hospital 
care in order to prevent injuries to self and others, and to 
establish a suitable symptomatic treatment. Exception 
is made for the few cases of the hebephrenic form with 
insidious onset. These patients may be cared for at home 
with safety for a considerable time. At the onset of the 
acute and subacute cases bed treatment should be prescribed 
for all cases. 


Insomnia at the onset may be controlled by lukewarm 
baths or sparing doses of a hypnotic, of which sulphonal 
or trional in ten to fifteen grain doses are the best. Condi- 
tions of excitement are best treated by prolonged warm 
baths (see p. 89). The extreme excitement sometimes 
encountered, especially in the catatonic form, may not 
yield to the simple warm bath, in which event one can 
often successfully employ cold packs (see p. 246), at 
first preceded by trional, sulphonal, or hyoscine hydro- 
bromate 2iro'"FU' S r * These, however, are not applied 
without some risk, and frequently require the supervision 
of a physician. If these measures fail to allay the excite- 
ment, nothing remains but confinement in a padded room 
with careful watching. Simple persuasion on the part of 
a well-trained, tactful nurse or physician often succeeds in 
bringing about quiet, at least temporarily, but this requires 
great patience, a kindly disposition, and good self-control. 

In the condition of depression at the onset of the 
disease the patient should be removed from all sources of 
irritation. Friendly encouragement, with change of 
environment from time to time, or simple occupation 
planned to distract the attention from self, are important 
features in the psychical treatment. The condition of 
nutrition as well as the digestive organs need careful 
attention. This is especially important in the stuporous 
states of the catatonic, where feeding by nasal or stomach 
tube is necessary to maintain nutrition. In this event 
eggs, hypophosphites or alcohol should be added to the 
liquid nourishment. 

After the subsidence of the acute symptoms, provided 
the patients are not untidy, are not subject to periods of 
excitement, and are able to take sufficient nourishment, it 
is desirable for them to return to their homes. In the case 


of women one has to consider the possibility of pregnancy. 
These patients may reside comfortably at home for many 
years, but finally, as a result of increasing deterioration, 
they drift into almshouses or back into insane hospitals. 
Finally it is most essential that the partially demented 
persons should be engaged in some regular employment, 
preferably with outdoor environment. This means often 
inhibits further development of deterioration. 


Tinzi e Vidriani, Contribute) clinico alia doctrino della Demenza. 
Praecoce, Rivista sperimentale di freniatria, T. XXV, 180. 
Christian, De la Demence Precoce, Annales Medico-Psychologique, 
T. IX, 43, 200, 420 ; T. X, 5, 177. 


Dementia paralytica, or general paresis of the insane, 
is a chronic progressive psychosis of middle age, character- 
ized clinically by progressive mental deterioration with 
symptoms of excitation of the central nervous system, lead- 
ing to absolute dementia and paralysis, and pathologically 
by a fairly definite series of organic changes in the brain 
and spinal cord, probably the result of autointoxication. 

Etiology. — The disease is unknown among the unciv- 
ilized nations and is most prevalent in western Europe 
and North America. It seems to be a disease of modern 
civilization. Not many years ago the negroes were free 
from the disease ; at the present time its percentage among 
them almost reaches that of the whites. Early in the 
past century the disease represented about five per cent, 
of the admissions to large foreign city insane institutions 
which now admit twenty to thirty per cent, of paretics. 
By far the greatest number of cases appear in large cities 
and manufacturing centres, while in farming districts the 
disease is very rare. It is from four to five times more 
prevalent among men than women, and is less prevalent 
among women of high standing. This disproportion is 
gradually decreasing. Women suffer more often from 
the depressive form and least often from the agitated 
form. The disease is more often one of middle life, rarely 
appearing before twenty-five or after fifty-five years of 
age. It occurs most often between thirty-five and forty 
years. The onset is later in women than in men. 



Eecently a number of cases have been reported between 
the ages of ten to twenty years. In these cases of demen- 
tia paralytica, syphilis and alcoholism were frequently 
found in the parents. Alzheimer 1 has recorded syphilis 
in seventy per cent, of these cases. The juvenile form is 
usually that of simple deterioration of long standing, with 
great prevalence of paralytic attacks. 

The disease is more frequent among the unmarried, 
especially prostitutes ; and married women are usually 
childless. Occasionally the disease occurs in man and 
wife ; sometimes tabes is present in one and dementia 
paralytica in the other. The male patients are drawn 
from all classes and from all professions and trades. 
Defective heredity is found in fifty per cent, of cases. 

Among the causes of the disease syphilis is the most 
prominent. Its prevalence varies, according to various 
authors, from eleven to seventy-seven per cent. According 
to the experience of Gudden in the Charite and Kraepelin 
at Heidelberg a clear history of syphilis cannot be estab- 
lished in more than thirty-four per cent, of cases. 2 The 
period between the syphilitic disease and the onset of 
dementia paralytica varies between two and twenty years, 
but more often occurs between ten and twenty years later. 
Other causes are alcoholic excesses, insolation, head injury, 
and mental shock, of which alcohol is by far the most 
prominent. Another important factor is the restless over- 
active life, coincident with the struggle for existence in 
large cities, and excesses in eating and drinking. 

In view of the uniform course of the disease leading to 
dementia and physical paralysis, accompanied by a gen- 
eral and extensive destructive process involving not only 

1 Alzheimer, Allg. Zeitschr. f. Psy., Bd. 52, S. 3. 

2 Berkely at Baltimore offers the same percentage. 


the central nervous system, but also the general vascular 
system, and to a limited extent the internal organs of 
the body, it seems probable that we have to do with an 
autointoxication process. We have the symptoms of 
excitation of the neurones ; their rapid destruction, grad- 
ual sclerosis, the occasional exacerbations of the symptoms, 
and the possibility of a regeneration of the neurones, all 
of which can be reproduced by experimentation upon test 
animals with any toxic material which causes a destruc- 
tion of the neurones. These anatomical facts are wholly 
in accord with the clinical observations, namely: the 
gradual onset, great clouding of consciousness, rapid or 
gradual deterioration and marked remissions, some of 
which almost approach complete recovery. While the 
involvement of the blood vessels and the broad extent of 
the lesion indicates that the toxin reaches the neurone by 
means of the blood vessels, yet the disease of the blood 
vessels stands in no definite relation to the anatomical 
or clinical picture. The involvement of the kidneys, 
heart, and the entire vascular system, the fragility of the 
bones, the alternate loss and increase of the body weight, 
ending at last in great emaciation, all speak for the pro- 
found disturbance of nutrition. 

The sudden and high elevation of temperature, as well 
as the prolonged subnormal temperature, and finally the 
paralytic attacks, judging from our experience in eclamp- 
sia, myxedema and uremia, can best be explained by 
intoxication arising from disturbance of metabolism. 
The high grade destruction of the neurones, which has 
been demonstrated by Nissl in some cases, and which has 
been regarded by Lissauer as the cause of the paralytic 
attacks, would speak for the sudden overwhelming of 
cortical neurones with a toxin. If one accepts the view 


that the toxin circulates in the blood, then the difference 
in the intensity of the destruction of the neurones and the 
paralytic attacks indicative of focal lesions in the cortex 
can be explained by the difference in the concentration 
of the toxin and a varying susceptibility of the cells in 
the different areas. 

The character of the toxin and the sources from which 
it arises are questions still in doubt. It seems probable 
that it arises from a profound disturbance of metabolism, 
in the production of which in a considerable number of 
cases syphilitic infection is the most prominent factor. Moe- 
bius and others go so far as to hold that both tabes and 
dementia paralytica are late manifestations of syphilis, a 
view which seems to be borne out by the experiments upon 
nine paretics cited by Krafft-Ebing. It will be impossible 
to accept a view that syphilis is the cause of dementia para- 
lytica until we can establish a history of syphilis in more 
than thirty-four per cent, of cases. Strumpell draws an 
analogy from the symptoms of paralysis in diphtheria, 
claiming that dementia results from the effects of a toxin 
which develops in consequence of the presence of the syphili- 
tic virus during the early stages of syphilis. It is possible 
that we may be able later to distinguish a difference in the 
dementia paralytica following syphilis and that following 
other causes. Thus far only a few cases can be selected 
which show a gummatous infiltration of the walls of the 
vessels of the brain. 

Late manifestations of syphilis arise within a compara- 
tively short time after primary symptoms, while the 
dementia characteristic of dementia paralytica does not 
occur in the greatest number of cases until after ten or 
more years have elapsed. For this reason dementia para- 
lytica cannot be regarded as a simple syphilitic disease. 


On the other hand in a considerable number of cases 
syphilis in some way is in a position to produce profound 
changes of metabolism from which develops a toxin, 
which is the direct cause of the pathological changes char- 
acteristic of dementia paralytica. Such a view obviates 
the difficulties in making a satisfactory explanation of the 
relationship between syphilis and dementia paralytica. 
Other etiological factors, as alcohol, lead, and excesses, 
would bear a similar causal relation to this disturbance of 

Pathological Anatomy. — The pathological changes here 
enumerated can as a whole be regarded as pathog- 
nomic of this disease. Hyperostoses and exostoses of the 
cranium, with or without thickening of the tables, are occa- 
sionally present. The dura is usually adherent to the 
calvarium in places. Pachymeningitis, interna and hema- 
toma are common. The false membrane is almost always 
situated on the vertex over the frontal, parietal, or tem- 
poral lobes, and is of varying thickness, from a thin, 
almost imperceptible rust-colored membrane, to a thick, 
firm, white membrane, with small or large, fresh or par- 
tially absorbed, clots. 

The pia is thickened, whitish, and translucent along the 
vessels, and especially over the vertex of the frontal and 
parietal lobes and the first three temporal convolutions. The 
internal surfaces of the frontal lobes are usually adherent. 
The leptomeningitis is always more intense over the poles of 
the frontal lobes. The Pacchionian granulations are usually 
increased in size. In thirty-three per cent, of cases the pia 
over the atrophied convolutions and broadened fissures is 
edematous. The convolutions are atrophied, especially in 
the frontal lobes, and to a less extent in the central convo- 
lutions. In these portions the cortex is narrow and often 


strongly adherent to the pia, tearing upon its removal, and 
the corona radialis is shrunken. In the other portions of 
the cortex, and in the basal ganglia, the atrophy is much 
less marked. The ventricles are dilated, and the choroid 
plexus contains many cysts. The ependyma, especially of 
the fourth ventricle, and the inner walls of the lateral ven- 
tricles, is covered with granulations, which give the 
usual glistening surfaces a frosted appearance. These 
granulations are composed of an increase of neuroglia, 
which in many cases has undergone hyaline degeneration. 
The weight of the brain is regularly below the normal, and 
in some cases of long duration may be reduced to nine 
hundred grams. The average weight is eleven hundred and 
sixty to thirteen hundred grams. 

Microscopically, 1 cytological changes of varying intensity 
are found scattered throughout the cortex. These changes 
in the neurones may be divided into the acute and the 
chronic corresponding to the character of the clinical 

The acute change, as observed when studied by the 
Nissl method, consists of a swelling of the body of the cell 
and its nucleus, and staining of the achromatic substance, so 
that the axis cylinder process can be traced for some dis- 
tance from the cell body. This change is represented by 
Figure 2, Plate 4, which should be compared with Figure 1, 
which represents a normal cell. Where the process has 
been more intense, corresponding to the more severe and 
rapid course of the disease, the chromatic substance breaks 
up completely, the nucleus swells out, and the whole cell 
appears very much as if it had been perforated with fine 

1 Binswanger, Die Pathologische Histologie der Grosshirnrinden-Erkran- 
kungen bei der allgemeinen progressiven Paralyse. 1893. Nissl, Archiv f . 
Psy., Bd. 28, S. 989. Heilbronner, Allgem. Zeitschr. f. Psy., Bd. 53, S. 172. 

Fig. 1 

Fig. 2 

Fig. 4 

Fig. 5 
Plate 4 

Fig. 3 

Fig. 6 

Fig. 1 — Normal large pyramidal cell. Fig. 2 — Acute alteration in dementia para- 
lytica. Fig 3 — Grave alteration in dementia paralytica. Fig. 4 — Cell shrinkage 
in dementia paralytica. Fig. 5 — Chronic cell change in dementia paralytica. 
Fisr. 6 — Chronic change with suDeriniDOsed acute chansre in dementia paralytica. 


shot as seen in Figure 3. This acute change uniformly 
involves the neurones of the entire cortex. The most 
profound type of the acute change, which, however, is 
encountered also in other destructive lesions, consists of an 
immediate dissolution of the cell body with a shrinkage of 
the nucleus which loses its membrane and its characteristic 
structure, becoming round and staining a uniform violet 
blue. The nucleus finally remains as a small structureless 
clump, with or without scanty residuals of the cell body. 
This process does not permit of restitution, which seems 
possible in the other processes of the acute type. 

Another change which apparently belongs among the 
chronic changes, is called by Nissl " cell shrinkage," (Figure 
4). It consists in a fading away and a shrinkage of the 
chromatic portions. Some portions, however, remain unin- 
volved for a very long time, such as the nuclear cap and the 
basal bodies. The nucleus is also involved ; its membrane 
partially or entirely disappears, so that the nucleus upon 
superficial observation may seem to be increased in size. 
The achromatic substance is affected only very slightly; 
however, the axis cylinder may be recognized and traced. 
Apparently, cell shrinkage should be regarded as a severe 
and irreparable change. 

The chronic change differs from the acute in that not all 
the neurones are equally involved. In some cases the nor- 
mal and the abnormal cells may be found lying along side 
of each other. There is a gradual sclerosis of the neurone, 
the cell body shrinking and becoming irregular in outline, 
especially about the base ; the nucleus loses its rotundity, 
is triangular or oblong, and the membrane folds upon itself, 
producing sharply stained bands. The chromatic and 
achromatic portions of the cell lose their characteristic 
structure and stain profusely. The nucleus appears at the 


periphery of the cell. In the darkly stained portions one 
often sees fine, clearly stained bands. The chronic change 
is represented in Figure 5. The smaller pyramidal cells 
in their shrinkage take on a star-like formation. It often 
happens that cells with this chronic change give evidence 
of a superimposed acute process, as seen in Figure 6. The 
difference in the intensity of the process in the different 
areas is probably due to difference in the power of resist- 
ance of the neurones. 

As yet no relationship has been established between the 
clinical symptoms and the pathological changes in the 
different areas, except where there are speech disturbances, 
word deafness and convulsions, in which cases there is 
uniformly found involvement of the temporal, parietal, and 
central convolutions. The nerve fibres of the cortex and 
the corona radialis present anatomical changes which bear 
a definite relationship to the extent of the process in the 
nerve cells. Where the clinical course has been prolonged 
and the neurones are much degenerated there remain but a 
very few normal fibres. Similar destruction of the nerve 
fibres may be found in senile dementia and epileptic 
insanity, but it is not as far advanced as in dementia 

As the result of the degeneration of the nerve cells and 
their processes, there is an atrophy of the cortex, which 
in extreme cases may shrink to one-half its normal width. 
This degeneration may be more marked about the vessels. 
The remaining cells are no longer arranged uniformly, but 
are turned in all directions, either closely pressed together, 
as seen in Figure 3, Plate 5, or surrounded by areas composed 
only of sclerotic tissue and vessels with thickened walls. Fig- 
ure 3 should be compared with the normal cortex as repre- 
sented in Figure 2. It is this anatomical condition which is 

Fig. 4 

Plate 5 

f . ■' -4 ■ ■ ■'. ■ • ' ' 

v : ' ; v ^ ' r-jj 
• "■■?. # t*/^i 

:' * : - •&?* 

'< - ,* t^ < 

«4 . * •* .4 ., • • > 

:.-V •••/■'■'. 

■> 4 

- » 

. * A. 

Fig. 3 

Fig. 6 

Fig. 1 — Cerebral cortex in idiocy. Fig. 2 — Normal cerebral cortex. Fig. 3 — Cere- 
bral cortex in dementia paralytica. Fig. 4 — Glia in normal cerebral cortex. 
Fig. 5 — Glosis with presence of spider cells in cortex in dementia paralytica. 
Fig. 6 — Showing the relation of spider cells with vessel walls in deep layers of 
cerebral cortex in dementia paralytica. 


most characteristic of dementia paralytica. The cell changes 
already described may be found in other conditions, but in 
none do all the elements of the cortex suffer to such a 
profound degree as here. In senile dementia, idiocy, and 
even in dementia praecox, many cells and fibres are de- 
stroyed, but the general conformation of the remaining 
elements is undisturbed. This distortion with the presence 
of scar tissue is present to a recognizable extent in dementia 
paralytica, even when the process is not far advanced. 

In the areas of degeneration there may be a considerable 
increase in the neuroglia tissue, in which the spider cells 
take a prominent part, appearing especially in the deeper 
cell layers of the cortex and about the blood vessels. 
This great increase of spider cells may be seen in Figures 
5 and 6, Plate 5, in comparison with Figure 4, which 
represents the normal amount of neuroglia present in the 
cortex. The increase in neuroglia does not necessarily 
correspond to the destruction of the nerve cells, as often 
normal nerve cells are surrounded by considerable neurog- 
lia, and, on the other hand, in the same areas all the 
nerve cells may have disappeared, without any appreciable 
increase of the neuroglia. Vascular changes in the cortex 
form a prominent part in the microscopical picture. The 
vessels are increased in number, their walls thickened and 
infiltrated with many round cells. Some of the vessels 
are dilated, a few are totally obliterated, and others show 
small aneurisms. 

The basal ganglia, central gray matter, and cerebellum 
also present degeneration of the neurones. Weigert has 
demonstrated an increase of neuroglia in the granular layer 
of the cerebellum, with a destruction of the Purkinje cells 
and their processes. The cranial nerve nuclei of the me- 
dulla show similar changes to those seen in the cortical cells. 


Gross brain lesions, such as we should expect to find 
where there have been paralytic attacks, are entirely lack- 
ing. Even cases of apoplectiform attacks, followed by 
hemiplegia or aphasia, lasting for some time, present no 

The spinal cord 1 is involved to a greater or less extent 
in almost all cases, the most important anatomical changes 
being degeneration of the fibres in the posterior and lateral 
columns, which lesions are usually combined. Fuestner 
found them alone only in twelve to nineteen per cent. o£ 
cases. The two sides are unevenly affected. Degenerative 
changes are occasionally found in the peripheral nerves. 
In the internal organs vascular changes are so frequently 
found that they seem to bear a definite relationship to the 
disease process. Of these atheroma of the aorta and arte- 
ritis of the vessels of the liver and kidney are the most 

Symptomatology. — From the onset there is apparent an 
increasing difficulty of apprehension of external impres- 
sions. The patients are distractible, inattentive, and 
unable to grasp clearly and sharply the character of the 
environment. Later they mistake persons and objects, 
fail to recognize former well-known objects and circum- 
stances, and overlook important matters in daily life. The 
attention is maintained only with effort. Long sentences 
are followed only with difficulty, and bits of wit are lost 
upon them. Business obligations are poorly performed. 

In this way the consciousness becomes clouded. The 
dreamy conduct of the patients often leads to the belief 
that they are in a constant state of intoxication. A con- 

1 Westphal, Allgemeine zeitschr. f . Psy., Bd. 20-21. Westphal, Archiv f. 
Psy., H. I, Bd. 12. Westphal, Virchow's Archiv, Bd. 39. Fuestner, Archiv 
f. Psy., Bd. 24. I. 


dition of mental torpor is quite characteristic of the early 
stages. These patients may answer questions quite cor- 
rectly and upon superficial examination seem to conduct 
themselves in accord with their environment, but at the 
same time they neither know where they are, with whom 
they are speaking, nor the significance of what is taking 
place about them. They fail to recognize the season or 
the time of day by the means close at hand. A patient 
may say that it is summer while looking out upon a 
snow-covered field and with his hands resting upon a hot 
radiator. This condition later reaches one of absolute 
disorientation, when the patients cannot perceive or elabo- 
rate any external impressions. 

Hallucinations play an unimportant part. In the 
greater number of cases none appear, but on the other 
hand a few may present hallucinations of all the senses 
for a short time. Hallucinations of sight are usual in 
patients with optic atrophy. 

The disturbance of apprehension is partially responsible 
for the profound defect of memory, which is one of the 
most prominent of the mental symptoms. At first, the 
memory becomes defective for recent events. The patients 
cannot tell what they did several days previously, or where 
they walked the evening before. If asked to figure five 
times fifteen, they reckon correctly five times ten, and five 
times five, but when they attempt to add the results, they 
have forgotten the first. The memory is especially defec- 
tive in the time element, the patients failing to record the 
time of the occurrence of events. They cannot inform you 
when the mail arrived, when they had breakfast, or how 
long they have been in the institution. Some of the pa- 
tients live so completely in the present that they may ask 
several times a day where they are, how long they have 


been in the institution, or if they have ever seen you 
before. This defect is often keenly appreciated by the 
patients, who complain of and sometimes devise means for 
correcting it. 

The early events of life are comparatively well retained 
for a long time, the patients being able to tell of their 
occupation, the former place of residence, and the child- 
hood. This remote memory also suffers late in the dis- 
ease, and here also the time element is the first to be 
affected. Dates of marriage, birth of children, and impor- 
tant events are completely forgotten. Finally they are 
unable to recall the names of the father, the children, or 
the place of birth. A married woman often forgets her 
maiden name. Lapses of memory, when periods are com- 
pletely forgotten, occur most frequently following epilepti- 
form or apoplectiform seizures. 

The store of ideas undergoes a progressive impoverish- 
ment, which finally leads to a complete destruction of all 
the mental possessions. The rapidity of this process varies 
with the intensity of the disease and the power of resist- 
ance, as well as the intelligence of the individual. The 
more intelligent resist longer, and the most frequented 
paths of thought are retained longest. As memory fails, 
its place in the intellectual life is often made good by the 
imagination. As real reminiscences disappear, invention 
runs riot. Whatever enters the mind is related as genu- 
ine; stories, or what may have been said by a fellow- 
patient, are now a part of their own experience. The 
patient was in a terrible railroad accident last night, in 
which a dozen were killed, and he escaped only by chance ; 
he led the troops at San Juan ; yesterday he had a confer- 
ence with the British Ambassador ; invented an airship in 
which he has travelled to China. He captured a hundred 


beautiful women from a Turkish harem, invented a new 
and inexpensive motive power for the automobile, which 
is now bringing him millions of money. These dream-like 
fabrications can lead to the greatest absurdities following 
suggestions from the listener. Of these, the patient may 
at first be a little doubtful, but at the next visit all doubt 
will have disappeared. 

It is not unusual at the onset for the patients to express 
some insight into their mental disease, complaining of 
their failing memory, the irritability, and the increasing 
difficulty of thought. Later, with increasing deterioration, 
all genuine insight disappears. The patients, on the con- 
trary, exhibit a feeling of well being ; they claim that they 
never felt stronger or enjoyed better mental vigor. At 
times during the course of the disease the patients may 
make various hypochondriacal complaints, but even then 
they fail to recognize the real symptoms of the disease. 

Impairment of judgment is another very prominent 
symptom. It may be the first to call attention to the 
disease. Objects of former criticism now fail to arouse 
comment. The former conservative principles which have 
made their business life a success are lost sight of, and 
new plans lack unity and system. Weighty obstacles are 
overlooked and senseless schemes produced with perfect 
serenity. Business and social standards are completely 
disregarded. Their conceptions have no bearing upon the 
environment, but centre almost entirely about themselves, 
so that they come to live in a sort of dream world, in 
which everything depends upon their own ideas and wishes. 
The formation of delusions, which in part arises as the result 
of this defect of judgment, varies very much in different 
cases. In some there are but few delusions, but in 
most the delusions form a prominent feature in the first 


stage of the disease. These delusions are transitory, 
unstable, without system, and show confusion and inco- 
herence. They are characterized by vagaries, senseless- 
ness, numerous variations and contradictions. 

The emotional life shows a profound disturbance. At 
first there is usually irritability. The patients are easily 
disturbed at home and work, are sullen, peevish, and apt 
to show considerable passion at trifling annoyance, in 
which they completely lose control of themselves. On 
the other hand, there may be noticed an unusual insensi- 
bility to the claims of others, indicative of the deteriora- 
tion of the finer feelings ; the patients fail to show 
sympathy at the suffering of their children, are indiffer- 
ent to immoral surroundings, and do not take the wonted 
pleasure in reading or professional pursuits. 

The emotional attitude is much in accord with the charac- 
ter of the delusions ; it is elated with expansive or dejected 
with depressing delusions. Later the emotional tone be- 
comes very unstable, and there are frequent and abrupt 
changes. In the midst of laughter they may break out 
in a storm of tears, or misery may give way to silly hap- 
piness. These changes of emotion may be brought about 
by simple suggestions or by raising or lowering the tone 
of voice, or by the expression of the face. A patient 
lying on the floor, complaining that he had lost all his 
organs, that he had no blood and could not breathe, when 
tickled in the ribs and asked how he felt, exclaimed, 
beginning to laugh, " I am feeling fine ; come and see me 
again." In the demented forms of the disease, where 
there may be only a few delusions, there is no especial 
tone to the emotions, the patients being in a condition of 
simple joy or irritable dissatisfaction most of the time. 

There is a profound change of disposition ; the former 


stability and independence of action gives way to progres- 
sive weakness of the will power. The patients become 
very tractable, but occasionally may be excessively stub- 
born. Early in the disease they are led to indulge in all 
sorts of excesses and sometimes persuaded to deed away 
property. When angered and determined to commit an 
assault upon some one, they may be easily influenced to 
desist by a simple suggestion. A patient about to leap 
from a third-story window because of fear, was readily 
prevented by the suggestion that it would be better to go 
down and jump up. Any impulse that arises may be 
acted upon without reference to the extreme difficulty of 
its accomplishment. One patient is said to have stepped 
out from the second-story window for the purpose of pick- 
ing up a cigar stump. 

In conduct the patients show a disregard for the demands 
of custom and law, are unconstrained, and often commit 
grave offences into which they have no insight. As a 
reason for such conduct, they often say that they acted 
so because it happened to come into their minds. The 
social restraints normally imposed upon one by the envi- 
ronment never interfere with the carrying out of the 
patients' purposes. They are quite reckless of personal 
safety, and occasionally injure themselves severely in 
their foolhardy actions. In conditions of great clouding 
of consciousness or in advanced deterioration there are 
sometimes present some symptoms characteristic of the 
catatonic form of dementia prsecox, such as catalepsy, 
verbigeration, negativism, and stereotyped movements, 
but these are transitory and change more readily and 
frequently than in that condition. 

Physical Symptoms. — The physical signs of the disease, 
in both the motor and the sensory fields, are as extensive 


and profound as the psychical. These may appear either 
before the mental symptoms or not until dementia has 
become well advanced ; usually they are coincident. 

Of the sensory symptoms headache is often the first to 
appear, accompanied by a feeling of pressure as if the head 
were being held in a vice, together with ringing in the ears 
and dizziness. The special senses at first give evidence of 
excitation, which later gives way to a state of insensibility, 
corresponding closely in degree to the stage of deteriora- 
tion. Some patients have difficulty in the recognition and 
localization of objects held before them, which by Fuerstner 
is ascribed to involvement of the occipital cortex. Hemi- 
anopsia occasionally follows apoplectiform or epileptiform 
attacks. Optic atrophy is found in five to twelve per cent, 
of the cases. The disturbance of the cutaneous sensations 
is quite often prominent; at first there are all sorts of 
indefinite pains, later analgesia appears, which may be so 
pronounced that needles can be thrust entirely through the 
limb without pain. Finally, the patients may pull out 
their hair, disturb an open wound, draw out their toe-nails, 
and persist in mangling their own flesh. 

Of the motor symptoms paralytic attacks, either epilep- 
tiform or apoplectiform, are very important, occurring in 
about sixty per cent, of cases. 

The epileptiform attacks may be very light, consisting 
only of a transitory dizziness with perhaps an inability to 
speak. An attack of this sort is often the first symptom 
to call attention to the disease. In the severer forms, 
which may be either of the Jacksonian or of the essential 
type, confusion or stupidity may usher in the attacks, 
which begin with a fall to the floor, loss of consciousness, 
and convulsive movements usually in one limb extending 
gradually to the others. It is noticeable in many cases 


that the movements are synchronous with the pulse. Con- 
vulsive movements may be confined to a single group of 
muscles or to one limb. The duration of the attack is 
from one to several hours, but sometimes clonic movements 
of varying intensity continue in one or more limbs for days. 
A condition similar to status epilepticus, where there are 
from twenty to one hundred attacks daily, may persist for 
days, often terminating in death. The attacks pass off 
slowly, sometimes leaving the patient in a condition of con- 
fusion. In the earlier stages of the psychosis, these attacks 
leave the patients in a condition of more profound deterio- 
ration, and sometimes with evidences of transient aphasia, 
hemiplegia, or hemianopsia. 

Apoplectiform attacks often occur, and may be the first 
important sign of the disease. In these attacks there is the 
usual loss of consciousness and stertorous breathing, with 
occasional high elevation of temperature, accompanied by 
hemiplegia and aphasia. In some attacks there is no loss 
of consciousness, simply the sudden appearance of paralysis. 
Transitory sensory disturbances can similarly appear as 
paresthesias, anaesthesias, or defects of vision. It is a dis- 
tinguishing feature of these apoplectiform attacks that the 
paralysis disappears quickly and without evident residuals. 

Other somewhat similar attacks occurring in the course 
of the disease are those in which there is a sudden develop- 
ment of extreme confusion, with motor restlessness, diffi- 
cult speech, flushing of the face and body, distention of the 
veins of the face, vomiting, and rise of temperature which 
may be excessive (one hundred to one hundred and seven 
degrees). These last from a few hours to a few days and 
pass away quickly, leaving the patient in his former state. 

The frequency of the apoplectiform and epileptiform 
attacks depends somewhat upon the character of the treat- 


ment. They may result from emotional disturbances, 
excesses in eating, and especially an accumulation of feces 
in the rectum. Cases with prolonged rest in bed are not 
as apt to develop these attacks. They are also most fre- 
quent in the demented form. 

Motor disturbances of the eye include occasional transi- 
tory paralysis of single muscles, also complete opthalmo- 
plegia, single or double ptosis, and nystagmus. Differences 
of the pupil occur in about fifty-seven per cent, of the cases, 
immobile pupils in about thirty-four per cent., and sluggish 
reaction to light in thirty-five and five-tenths per cent. 

The muscles of the face lose their tone, the naso-labial 
fold and other lines of expression disappear, and the counte- 
nance becomes expressionless. This washed out, expres- 
sionless character of the countenance is well represented 
by the group of three paretics seen in Plate 6. Lack of 
tone in the muscular system is also seen in their slouching 
and inelastic attitude. There is also a loss of control of 
these muscles, giving rise to incoordination noticeable 
mostly when the mouth or eyes are forcibly opened. A 
fine tremor of these muscles is almost always present. The 
voice loses its characteristic tone, becoming monotonous. 
Changes in the voice often are the first physical signs to 
appear among singers. Tremor of the tongue, which may 
be either finely fibrillary or coarse and retractive, is a con- 
stant sign. In advanced cases there is often a rolling of 
the tongue about the mouth as if it were a quid. This in 
some cases has been explained by the presence of areas of 
anaesthesia of the mucous membrane. Gritting of the 
teeth is occasionally associated with these movements of 
the tongue or may be present alone. 

Disturbances of speech are among the most character- 
istic symptoms. They are of two kinds, aphasia and 





defective articulation. Aphasia appears only after para- 
lytic attacks and is transitory. Paraphasia, which may 
appear at the same time, is more persistent and sometimes 
lasts several months. Word blindness and word deafness 
are rarely encountered. There is occasionally agrammat- 
ism, as seen in the misuse of infinitives and omission of 
conjunctions. There may be an elision of syllables, as in 
the use of elexity for electricity, or a reduplication of 
syllables, as electricicity, and finally there may be ten- 
dency to repeat syllables forming a genuine word clonus, 
as Massachusetts-etts-etts-etts. 

The disturbance of articulation may appear after para- 
lytic attacks, but more often occurs independently of 
them. As the result of difficulty in movement of the lips 
and tongue, syllables are poorly united, making the speech 
indistinct. Gliding over the syllables gives rise to a char- 
acteristic slurring. Frequent pauses are made between 
syllables or words, and when accompanied by a fall in the 
tone of voice produce a scanning speech. These difficul- 
ties lead to the substitution of words or syllables similar in 
sound but more easily pronounced, or the elision of diffi- 
cult syllables. Many of the patients, in their efforts to 
overcome these difficulties, stutter and produce an explo- 
sive speech. The patients often appreciate the difficulties 
of speech, but are ready to explain that these are due to 
dryness of the mouth or loss of teeth. Speech disturbances 
are more readily observed in ordinary conversation. The 
test words and phrases, if used, should be introduced into 
long sentences, because, if the attention is concentrated 
upon single words they may be pronounced correctly. 
Words and phrases used for this purpose are electricity 
national intelligency, methodist episcopal, ninth riding 
Massachusetts artillery brigade, etc. Defects in speech 


may also be elicited by asking the patients to read aloud. 
Voluntary writing usually shows defects similar to those 
noticed in speech, but they are proportionately more promi- 
nent (Plates 7 and 8 and fig. 2). Patients, on the other 
hand, who speak clearly may produce on paper an unin- 
telligible muddle of words and syllables. In advanced 
cases there is complete agraphia (figs. 3 and 4). The 
patients are then able to make but a few unintelligible 
marks, and many even give up without making a sign. 
The handwriting is characterized by irregularities caused 
by the tremor, excessive pressure on the pen, and careless- 
ness. The irregularities are more extensive than in the 
case of the senile, whose lines show the effect of a fine 
regular tremor. 

Ataxia is less prominent and appears first of all in those 
finer movements such as are employed by skilled workmen. 
Later the more delicate movements in locomotion, such as 
turning about quickly, become affected. Finally all move- 
ments become ataxic. The clothing cannot be readily 
buttoned, the gait is unsteady, swaying and shuffling, 
and may be spastic where there is involvement of the 
lateral columns of the cord. The Romberg symptom 
appears in involvement of the posterior columns. In 
fact, it is not uncommon to see cases of tabes dorsalis 
develop into paresis after a duration of some years, to 
which condition the name of ascending paresis has been 
given. Intention tremor may be present, and in a few 
cases choreiform movements, which may be marked enough 
to simulate Huntington's chorea. Contractures and mus- 
cular atrophy may appear late in the course of the disease. 

The tendon reflexes are exaggerated in seventy per cent, 
of the cases and are absent in about twenty-five per cent* 
The loss of patellar reflex is usually associated with immo- 

Fig. 2 

Fig. 3 

Fig. 4 

Fig. 2 shows, besides the excessive pressure elision, substitution of letters and 
syllables. The patient has attempted to write from dictation, " Around the 
rugged rock the ragged rascal ran." 

Figs. 3 and 4 represent conditions which approach complete agraphia, in which the 
patients, after an attempt to write, simply laid the pen down. 



bile pupils and myosis. The electrical irritability of the 
muscles is increased at first, but later diminished. Dis- 
turbances of the bladder are often present, both retention 
and incontinence, the latter usually being the result of 
the former. Sluggishness of the bowels may extend to 
obstinate constipation. Finally in the end stages, there 
is paralysis of both sphincters. The sexual power may 
be increased at the onset, but later it is diminished. The 
vasomotor disturbances consist of erythema, persistent 
blushing of the skin, rush of blood to the head, and der- 
mographia. The so-called trophic changes, acute decubitus, 
increased fragility of the ribs, and othematoma are of 
frequent occurrence, especially the first. By some, pneu- 
monia, which often leads to fatal outcome, is regarded as 
a disturbance of the vagus nerve, which contains the 
trophic fibres for the lungs. Furthermore, there is a loss 
of vitality and of the power of repair in all tissues, so 
that a very trifling injury may lead to an extensive lesion. 
Acute decubitus once started is difficult to heal. 

The temperature during the course of the disease is 
mostly normal, except toward the end, when it is apt to 
be subnormal. A peculiarity is the excessive elevation 
of temperature with trifling disturbances, such as mild 
bronchitis, distention of the bladder, or constipation. 
There is often a rise of temperature during a paralytic 
attack, and finally, as mentioned before, there may be a 
short period of a few hours or more of an excessively 
high temperature without apparent adequate cause. 

The sleep is usually somewhat disturbed during the 
first stage and more so during the second, where there is 
motor excitement, but in the last stage the patients are 
sluggish and may sleep much of the time. This varies, 
however, as in some cases the patients may from the 


onset show a tendency to sleep continually, while in other 
cases insomnia persists throughout the whole course. 
The appetite suffers at first and during excitement, but 
later the patients eat well. The condition of nutrition 
is poor until excitement subsides and deterioration is well 
advanced, when there is usually a great increase in weight, 
which may last until death. Sometimes loss of appetite 
and impaired nutrition coexist, leading to extreme emacia- 
tion. Other evidences of the profound disturbance of 
metabolism occurring in dementia paralytica are the pres- 
ence of albumen and sugar in the urine and fall of the 
percentage of hemoglobin. 

The mental symptoms enumerated above represent in 
general the clinical picture. The grouping of the individ- 
ual symptoms, however, varies widely in different cases. 
This has led to the recognition of four types of cases : 
the demented, expansive, agitated, and depressive, each 
of which presents a somewhat different course from the 
onset. The deviations from these types deter many from 
the acceptance of this differentiation, but its value 
becomes apparent in a considerable number of cases 
where one is able to forecast the future duration of the 
disease and the character of many of the symptoms. 

The demented form, because of its great predominance, 
and its simple character with deterioration, unaccompanied 
by many delusions and hallucinations and its rapid 
course without remissions, should be regarded as the type 
of the disease. The clinical picture of megalomania, 
which has been and still is by some regarded as the proto- 
type of the disease, has in recent years become less and 
less prominent, until it is now encountered in less than 
twenty-five per cent, of cases. 

















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Demented Form 

The demented form is characterized by gradually pro- 
gressive mental deterioration without prominence of either 
hallucinations, delusions, or great psycho-motor disturb- 
ance. There may be frequent transitory periods of deliri- 
ous excitement, anxious unrest with hypochondriacal ideas, 
depression, delusional states, or periods of megalomania, 
but all of these are insignificant when compared with the 
rapid advance of profound deterioration. 

The onset of this form is very gradual. The symptoms 
at first may resemble those of neurasthenia; patients 
complain of inability to apply themselves to work, loss of 
energy, indefinite pains, feeling of pressure in the head, 
and irritability. They are forgetful and flighty, at times 
drowsy, and at others somewhat confused, but have a 
clear insight into this condition. Soon mental deteriora- 
tion becomes apparent in the inability to explain their 
actions, in errors of judgment, failure of memory, and 
absence of the usual moral feelings. Their work is irk- 
some, and they occasionally fall asleep over it. They 
forget to go to meals, make mistakes in figures, and over- 
look important matters. They are usually good-natured, 
tractable, are easily led astray, and often drink to intoxi- 
cation. In some cases, however, they become obstinate 
and self-willed. The household suffers, dinner is uncooked 
or improperly seasoned, and the children are neglected. 
Patients are reckless and may even act in opposition 
to established precepts. In conversation the thought is 
sluggish and lacks individuality. Soon disturbance of 
apprehension appears, when the patients fail to compre- 
hend thoroughly their environment, lose account of time, 
get confused as to place, and mistake persons. 


At this time a few delusions may appear, either de- 
pressive or expansive, sometimes with hallucinations of 
hearing. The delusions are very weak, childish, and 
easily influenced by suggestion. Occasionally there are 
weak attempts at fabrication. Sudden changes of emo- 
tion are more prominent at first, when the feelings are 
easily influenced by suggestion; but later the patients 
become uniformly dull and apathetic. They are perfectly 
contented wherever placed, as long as the simplest needs 
are satisfied, such as food, drink, and tobacco. They 
have a complacent smile when addressed, greet strangers 
very cordially, and are very friendly with every one. 
Often at first there is some insight, when the patients 
complain of slowness of thought and failure of memory, 
but the later increasing deterioration obscures this feeble 
capacity. On the other hand, they may express a feeling 
of well-being and perfect confidence of their business 

The capacity for work very soon suffers. The patients 
become careless in their duties, forget engagements, allow 
letters to go unanswered, go to work at all hours, and 
finally stay away altogether. It sometimes happens that 
they struggle along with their work, realizing and worry- 
ing over difficulties and frequent errors. Others neglect 
their occupation to look after all sorts of unnecessary and 
unprofitable affairs. They may become restless, wander- 
ing restlessly about, indulge in excesses or commit petty 
crimes. They lack will power, are easily led astray, are 
unable to care for themselves, forget when to go to meals, 
and neglect their personal appearance. On the contrary, 
some patients are inaccessible, repulsive, and surly, an- 
swering questions as if angry, rebuffing friendly advances 
and opposing without reason anything desired of them. 





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A few patients, in spite of an advanced stage of de- 
terioration, present a good demeanor. They greet one 
correctly, and appear perfectly at ease in talking about 
themselves, but at the same time are disoriented, and are 
unable to give any coherent account of their lives. The 
patients usually enjoy a good appetite, sleep well, and 
present the picture of health. The mental deterioration 
may have been so gradual and so unobtrusive that the 
friends and relatives fail to appreciate the profound degree 
of deterioration exhibited. 

This form of dementia paralytica embraces forty per 
cent, of the cases. The duration is rather shorter, seven- 
teen per cent, of cases dying within six months, and a few 
living over three years. Paralytic attacks occur in almost 
one-half of the cases. Eemissions are less frequent than 
in the other forms. 

Expansive Form 

This form is characterized by great prominence of expan- 
sive delusions, a prolonged course, and greater prevalence of 

The onset is usually gradual, with change of character, 
difficulty of mental application, and signs of failing mem- 
ory and judgment. Fainting spells, short periods of ex- 
citement, and transitory speech disturbances are often the 
first symptoms to attract attention, although the disease 
may have been in progress for some time. Occasionally 
the onset is quite sudden. 

The patients develop a marked feeling of well-being; 
they are bright, affable, talkative, and energetic. They 
busy themselves with new and elaborate schemes for get- 
ting wealthy, stake out property, and draw designs for 


wonderful machines. They are busy from early morning 
to late at night, soliciting patronage, ordering large quan- 
tities of material for building and for other purposes. 
The numerous expansive delusions at first are within the 
range of possibility and may appear attractive to the 
unsuspecting, but soon pass into the realm of absurd 
imagination, reminding one very much of the prattle of 
children, and presenting, with the restlessness, the char- 
acteristic picture of megalomania. The patients claim 
never to have felt better in their lives, can lift tons, can 
whip the best man on earth, have the strength of a 
thousand horses, and can move a train. 

They believe their English the best; they speak as 
fluently several other languages ; their voice is clear and 
distinct and can be heard for many blocks, because of its 
excellent qualities. They have the inspiration to write a 
book ; can compose beautiful poems ; can deliver an ora- 
tion on any subject. They associate only with the most 
cultured people; only the genuine blue blood courses 
through their veins; they are going to build a marble 
mansion at Newport, and have a floating palace. Busi- 
ness is flourishing ; they are making a " mint of money," 
have several gangs of men working for them, and still 
there is more work than they can attend to ; besides their 
regular business, chickens are being raised by a special 
improvised method at an enormous profit; they have 
secured rich gold claims in Alaska, which are doubling 
in wealth daily. 

Formerly they were brakemen, but now run the fastest 
and finest train in the world, from New York to Chicago 
without a single stop, allowing none but millionaires to 
ride ; besides a profitable law business, they are now 
engaged in writing a novel which will startle the world, 


and for which they have received priceless offers from 
publishers in this country and in Europe. A ship car- 
penter developed wonderful power in his eyes, so that he 
could detect defective wood in a vessel by simply standing 
in the hold and looking outward, and for this reason he 
was appointed detective of a marine insurance company, 
and had travelled all over the world inspecting vessels. 
He had become so wealthy that all the banks in the state 
were in his possession. 

A seamstress had devised a new method for cutting 
dresses, which had won her world-wide fame, having been 
called to all of the courts of Europe because of her won- 
derful success. She herself could cut and sew a hundred 
dresses a day, and had under her five hundred girls, all of 
whom used golden thread. She could sew on a thousand 
buttons a minute. A jockey had discovered a new way 
of breeding and training runners, and now from his Ken- 
tucky ranch was supplying every circuit and handicap 
with winners. 

The utter absurdities which increase from day to day 
are proof of the increasing weakness. The delusions 
abound in contradictions and become more incoherent, 
the product of a more dreamy ingenuity. The patient 
now drives the largest engine in the world, drawing a 
thousand palace cars, all lined with gold and trimmed 
with pearls, which encircles the globe every twenty-four 
hours, stopping only at New York, San Francisco, Calcutta, 
Paris, and London. He now has formed a chicken trust 
to extend over the whole earth, and will reconstruct the 
social system of the world, so that only the Chinese will 
be employed in hatching the eggs. Another has a most 
wonderful herd of cattle, whose horns are forty feet high, 
whose eyes are diamonds, whose feet are gold, and each 


cow produces five hundred pails of milk in twenty-four 
hours, the patient himself milking a thousand a day. 

The patients are the most beautiful beings that ever 
lived. They have married seven hundred millionaires, 
have twenty thousand children, all of whom have gold 
slippers and gold dresses ; they themselves wear only dia- 
mond trimmings ; they can fly away in the air to a world 
where there is a castle ten thousand miles long filled with 
lovely people who do nothing but amuse themselves. They 
are not human but divine, can create a universe, visit all 
the stars, have sent Christ to Mars ; whatever they touch 
turns to gold. They know all sciences, are the greatest 
physicians in existence; will build a hospital of marble 
twenty stories high, provided with a bar for the doctors, 
where the choicest wines and the best Havana cigars 
will be supplied ; and there will be a dissecting room, with 
a huge ice box, where ten thousand bodies can be kept all 
the time. 

They will build a tunnel through the earth and bring 
all the Chinamen here to work. One patient said that he 
was going to build towns ; that he had been to Washington 
to see the President, that he wanted six thousand billion 
gun-boats, one million bomb-shell boats, one million marines, 
and that he would cross the ocean and blow up all of the 
countries and bring the people out west and put them on 
farms ; that he would blow up the Queen's buildings, and 
that he would give each one of the marines two bags, and 
each would have to go two times in order to bring away 
the silks and diamonds. 

These delusions are almost entirely self-centred. They 
may change rapidly, each day new and more extravagant 
ideas appearing, which are filled with the most glaring 
contradictions. In women the tendency to expansiveness 


is less marked. Hallucinations are rarely encountered and 
never take a very prominent part in the disease picture. 

Consciousness becomes somewhat clouded after the de- 
velopment of the delusions, and may be from the onset, 
especially where it is subacute. There is usually disorien- 
tation as to place and persons. The patients are too much 
absorbed in their numerous ideas to note the surroundings 
or to take account of time. Later they become acquainted 
with the place and a few of the persons, but they rarely 
know the month, day, or the year. 

The content of thought is centred entirely about self 
and the many varied delusions. At first it is usually 
coherent, although at times, in connection with great 
psycho-motor restlessness, there may be incoherence, dis- 
tractibility, and sometimes flight of ideas. The patient 
is usually talkative, and may produce a continuous stream 
of delusions. Incoherence of thought is more evident in 
their letters, the following being a sample : — 

" Dear Billy : The early part of the twentieth cen- 
tury has made wonderful strides from its start, and but 
for a fortunate accident the men of science, education, 
culture and God-like Christianity, and women of gazelle- 
like charms, whose very presence is a panacea, would have 
come far short in the greatest desideratum on earth or the 
whole universe. The tortures of the Spanish Inquisition 
have been found to be the greatest elixir for the health 
of those whose only relief to that time had been the 
tender arms of our Saviour. Our laws have been changed 
and perjury, theft, deceptions of every conceivable manners 
of conveyance of information have been cut off, violence, 
and assault and battery. What a glorious century ! This 
has been a year that can never be forgotten. N — o 
became a Christian the last of the year. Billy became a 


Christian. It would have been a case for those scientific 
men to make a study of unheard tortures to cure this. 
Grandior malum grand ior bonum." 

The emotional attitude corresponds closely to the content 
of the delusions ; the patients are cheerful, happy, hopeful, 
contented, exalted. Everything in the environment is pleas- 
ing ; they are in luxurious quarters, have the best of food, 
plenty of servants, fine clothing, fast horses, and are asso- 
ciated with the finest men in the world. It often happens 
that for a short time, a few moments or hours, rarely days, 
they lose spirits and become depressed, complaining of con- 
finement, and expressing hypochondriacal delusions, or weep 
bitterly because of harassing persecutions. Even when 
most miserable it is possible by suggestions to reestablish 
the feeling of well-being, showing the great instability of 
the emotional condition. Irritability is always present, 
manifesting itself upon the slightest provocation. Dis- 
agreements or doubts relative to their superiority or 
immense wealth may arouse anger or even an aggressive 
attack. Later in the course of the disease this disappears, 
leaving the patients in a uniform state of quiet cheerful- 
ness in spite of their bedridden condition with filthiness, 
paralysis, and even contractures. A paretic on his death- 
bed, when asked how he feels, often says with some ani- 
mation, " fine, fine." 

The psycho-motor condition exhibits more or less excite- 
ment from the onset and may reach an extreme degree. 
At first the patients are restless, bustling about on new 
and important business, remaining up until late at night, 
devising plans, writing many letters, travelling about from 
place to place. They are very talkative and make con- 
fidants of every one they meet. For short periods in the 
course of the disease they may develop extreme restless- 


ness, with insomnia, complete clouding of consciousness, 
recklessness, aggressiveness, and impulsiveness. They 
shout from fear, mutilate their own bodies, and rush about 
blindly diving into any obstacle. It is impossible to 
attract their attention or to get coherent answers. They 
fight off imaginary enemies and shout threats and curses. 
These conditions of excitement rarely last longer than a 
few hours or days, disappearing gradually, and usually 
leave the patient in a state of more profound deterioration. 

In actions the patients soon become foolish and show 
a lack of judgment and moral obtuseness. They develop 
bad habits : smoke or swear, enjoy telling obscene stories, 
seek the company of lascivious women, and become dis- 
orderly in dress and careless in appearance. They may 
assault or commit thefts, but every action shows an 
absence of plan, recklessness, and utter disregard for 
others. When confronted with their observed behavior, 
it is all denied with perfect serenity. 

As the disease advances, the activity is limited to the 
production of unintelligible letters and plans, scribbling 
on paper, and collecting useless rubbish. The patients are 
happy and contented throughout it all, invariably assert- 
ing with brightening countenance that they are feeling fine. 
They may be heard mumbling to themselves, " millions," 
"fine horses," "beautiful women," "grand mansions," — 
mere relics of former ideas which now represent the last 
traces of their intellectual life. It sometimes happens 
that the expansive form passes over into the depressive, 
and vice versa, and this may take place several times, 
simulating the picture of manic-depressive insanity. 

The expansive form comprises from fifteen to sixteen 
per cent, of the paretics, and the duration is more prolonged, 
less than one-third of the cases dying within two years. 


A few cases extend through seven to fifteen years. Remis- 
sions occur in one-third of the cases. 

Agitated Form 

This form is characterized by its relatively sudden onset 
ivith a condition of great motor excitement and the pres- 
ence of the most extremely expansive delusions, great cloud- 
ing of consciousness and a short course. 

It represents a special group of the expansive form and 
constitutes about ten per cent, of the paretics. It may 
usher in the disease process, presenting great similarity to 
the picture of delirium tremens. A change of disposition 
is often noticed for a time previous to the sudden out- 
break. The patients suddenly become very energetic, 
expressing a pronounced feeling of well-being. They are 
born again, possess the ambition and the strength of ten 
thousand men ; could carry an ocean vessel or fly to the 
moon in a second. They have acquired all knowledge, 
can educate a thousand men an hour, teaching them to 
speak every known language. They themselves are God, 
God over God, have created God and the universe ; have 
been everywhere from the heights of heaven to the depths 
of hell. They are now establishing a new method of 
reckoning time ; by their decree the days are to be one 
thousand hours long, and the weeks are to contain one 
thousand days, and the years ten thousand months. They 
know how to create animals, and by a new formula man 
shall be increased a hundred-fold in size and shall have 
a third eye. The world moves and stands at their com- 
mand. They are interested in all wars and have mar- 
shalled huge armies. All great battles have been won by 
them. Their wealth is fabulous, more than any one man 


ever possessed before. All quantities are reckoned in the 
ten thousand billions ; they own ten thousand billion 
houses ; ten thousand billion cows ; ten thousand billion 
acres of land, etc. Their houses are built of Italian 
marble, with gilded domes set with diamonds ; the floors 
are of onyx, all furniture is of pure gold, and the hang- 
ings are of the finest fabric, trimmed with pearls and 
sapphires. Their ideas become more and more expansive, 
and finally seem even to surpass the bounds of imagina- 

Very often they give expression to a few pessimistic 
ideas which may be hypochondriacal : they are suffering 
untold misery from sharp pains in the back ; some one 
entered the room at night and disembowelled them, so that 
the following morning they could not go to stool ; miles of 
fine electric wires have been placed in the flesh, about the 
limbs and completely filling the skull, through which elec- 
trical currents are nightly applied, causing the flesh to 
burn. There may be some insight into the failing mem- 
ory and the defective nutrition, which leads them mo- 
mentarily to fear that they are suffering from cancer of 
the most malignant type, but at the same time one is 
assured that they are undergoing a process of purification 
which will leave them healthier and mightier. Sometimes 
they are perplexed at their own stupidity for allowing 
themselves to be confined in a hospital instead of going 
to Europe to consummate a deal by which millions would 
have been made. Hallucinations of sight and hearing 
may be present, but are not prominent, failing to influence 
the clinical picture to any extent. 

The psycho^motor condition is much disturbed, showing 
great restlessness and occasional impulsive movements. 
The patients are talkative, sing, laugh, shout, and prattle 


away like children over their innumerable plans and many 
pleasures. They are constantly in motion, going from 
one thing to another, working in a planless way on vari- 
ous schemes, scribbling unintelligible letters to millionaire 
friends, issuing commands to military staffs, and sending 
cablegrams to the different crowned heads. They have 
no care for themselves, neglect personal appearance, forget 
about eating, smear their dresses or the walls with the food 
placed before them, masturbate, and expose themselves 

The association of ideas is somewhat incoherent, passing 
rapidly from one idea to another, often with a flight of 
ideas. It centres entirely about themselves and their plans. 
There is a marked irritability, interference quickly leading 
to an outburst of passion, with cursing, threats, and ag- 
gressiveness. The emotional attitude is usually one of 
great exhilaration. Physically, the condition of nutrition 
suffers profoundly, and there is a great loss of weight, 
because of the small amount of food ingested and great 
restlessness. The temperature may be subnormal. 

A few cases of the agitated form may be characterized 
as the " galloping variety" in which there is a rapidly fatal 
course with a clinical picture very similar to that of an 
" Acute Delirium. ,, These cases present an extreme grade 
of excitement and profound clouding of consciousness, lead- 
ing in a few weeks or months to fatal collapse. This con- 
dition sometimes represents the end stage of the" agitated 
or of the depressed form. The patients are completely 
confused, unable to comprehend the surroundings or to 
respond to questions. They are noisy, shouting and sing- 
ing, producing an unintelligible babble, with many repe- 
titions of syllables or purely inarticulate sounds. The 
restlessness is extreme, the patients being in constant 


motion, pounding the bed or wall, forcing the legs up and 
down, running about the room, slapping their hands, waltz- 
ing to and fro, and bruising themselves extensively by their 
reckless movements. The weight falls rapidly, the tem- 
perature becomes slightly elevated, and the heart's action 
feeble and irregular. Epileptiform and apoplectiform 
attacks are frequent. After a few weeks or months the 
restlessness subsides into a condition of stupor, in which 
the movements are uncertain and tremulous. The tem- 
perature becomes elevated as the result of infection from 
the various wounds or acute decubitus, the mouth is filled 
with sordes, profuse perspiration and diarrhoea appear, 
which with heart failure lead to death. 

Remissions occur in one-fourth of the cases. Paralytic 
attacks are frequent. The duration in more than two- 
thirds of the cases is less than two years. 

Depressed Form 

This form is characterized by the depressed tone of the 
emotional attitude and of the delusions throughout the whole 
course of the disease. 

The onset of the disease in this form is insidious. The 
patients notice their failing memory, their decreasing power 
of application, their greater weariness upon exertion, and 
their change of disposition. The mind becomes centred 
upon their condition and they become despondent over it. 
The persistent headaches, the numerous pains, and failing 
memory lead them to consult one physician after another. 
They soon become hypochondriacal, claim that they are 
syphilitic, that they can never recover, and that they are 
suffering from a complication of diseases. Very often 
this condition is primarily diagnosticated and treated as 


Their hypochondriacal complaints sooner or later become 
entirely senseless. They then complain that the scalp is 
rotting away, the skull is filling in with bone, causing the 
brain to shrink, the mouth is filled with sores, the sense 
of taste is lost, the throat is clogged up, so that food passes 
up into the brain, the stomach is melted away, and the 
intestines are so paralyzed that there has been an accumu- 
lation of excrement within them for many months, the 
kidneys have been moved, so that water passes directly 
through them. They claim that they are dead, the blood 
has ceased to circulate, and they have turned to stone. The 
testicles have dried up, and their manhood has disappeared, 
a false passage has formed so that the " vital fluid " passes 
out of the rectum. In connection with these ideas they 
are constantly fingering different parts of the body, espe- 
cially the face and sexual organs. They may sit for hours 
with hands on their throat for fear feces will pass into 
the mouth, or may lie abed as if dead, claiming that they 
would fall apart if moved. 

Delusions of self-accusation are usually associated with 
these hypochondriacal ideas and occasionally predominate 
in the clinical picture. The patients believe themselves 
great sinners, that they have committed the unpardonable 
sin, must die on the cross, have stolen property, and 
injured their children. They have caused the death of a 
friend by negligence, and every one knows that they are 
murderers. They persist that they have always been 
impure and have led many astray. A patient moaned for 
months because he had not provided his family with suffi- 
cient food and was being held up to the whole world as an 
example and must suffer the penalty of death. Very often 
in connection with these ideas of self -accusation they are 
fearful, because they are being constantly watched, expect- 


ing at any moment to be imprisoned or carried away to 
the scaffold. 

Delusions of persecution may exist independently of the 
self-accusations, when they suspect plots against their 
lives, and complain that their families are being outraged. 
They are being regarded as desperadoes on whose head 
there is a high price. The troops have been summoned 
to escort them into exile. 

Hallucinations of hearing often accompany these vari- 
ous delusions. The patients listen to the reading of their 
own indictment, are slandered by a crowd of men outside, 
or overhear an intrigue against them. 

The consciousness soon becomes much clouded. There 
is considerable disorientation, friends are mistaken, and 
time is confused. Occurrences in the surroundings have 
reference only to themselves. The bathing of others 
suggests to their minds that they have polluted their 
fellow-patients, and the preparation for the morning walk 
signifies that the whole company are getting ready to 
attend their public prosecution. At the table others are 
deprived of food on their account. In this condition 
they develop great anxiety with restlessness; pace back 
and forth in their rooms, moaning and groaning, some- 
times uttering single expressions, as " death," "destruc- 
tion," pick at their finger-nails, pull out their hair, are 
unable to eat, and refuse to enter the dining room or even 
leave their own rooms. Every unusual sound causes them 
to shudder and shrink back farther into their rooms, 
because of intense fear. Finally they cannot be persuaded 
to leave the bed, but lie huddled up at one side, with the 
head buried in the clothing. In this condition they may 
attempt suicide or mutilate their own bodies ; one patient 
tore through the anal sphincter into the vagina with her 


hand. Extreme anxiety with restlessness does not exist 
very long at a time, usually only for a few hours or a 
few days. In the interval the patients are quiet but 
despondent and seclusive. Although retaining many of 
the depressive delusions, they show no emotion. 

The mental depression is not always uniform, as one 
occasionally notices a feeling of well-being or indifference, 
and some humor, which by the shorter duration serves 
to differentiate this depressed condition from that found 
in other psychoses, especially melancholia of involution. 
Stuporous states appear at times, when the patients are 
mute, perhaps resistive, lying abed in one position oblivi- 
ous to the surroundings, refusing nourishment and allow- 
ing the feces and urine to pass unheeded. They may be 
emotional at times, and even lachrymose, or may show some 
anxiety. Hallucinations and illusions may be more or 
less prominent or entirely wanting during the stupor, 
which may last for several months. 

A few cases occur in this form, which simulate for a 
time paranoia or the paranoid form of dementia prcecox. 
The chief symptom is a coherent system of delusions of 
persecution with clear consciousness, a coherent train of 
thought, and a normal emotional attitude. After some 
months, or perhaps a year, contradictions, infrequent repe- 
titions, or incoherence in thought and weakness in manner 
make it evident that there is a rapid deterioration process. 
The patients adhere to the delusions less persistently, the 
delusions fail to form the basis for their actions, and their 
judgment shows great weakness. 

The depressive form of dementia paralytica comprises 
one-fourth of the cases, and ■ appears rather late in life, 
mostly after forty years of age. Remissions in this form 
are rare, occurring in less than twelve per cent, of the cases. 


The course is rather short, as the greater number die within 
two years. 

Course. — Dementia paralytica has been divided into 
three stages by many writers : the stage of onset, the stage 
of acute symptoms, and the terminal stage of dementia. 
The lines of division are very indefinite, as the first stage 
may very quickly pass into the acute stage, when the 
symptoms remain in abeyance for a few years, or the case 
may be one of apathetic deterioration from the onset, 
devoid of any prominent symptoms indicative of definite 
stages. The terminal stage is apt to be prolonged. In it 
the patients are dull, stupid, apathetic, entirely indifferent 
to their surroundings, unable to care for themselves or 
occasionally expressing incoherent fragments of former 
delusions. They sit unoccupied save for the taking of 
nourishment, to which they often have to be helped. The 
physical symptoms in this stage advance to general paresis 
of all of the muscles, necessitating confinement in bed. 
Sensation is greatly impaired, muscular atrophy and weak- 
ness become marked, and finally contractures appear. In 
the end patients become nothing more than vegetating 
organisms. The physical signs in the different stages vary 
considerably and stand in no definite relation to the mental 
symptoms appearing before, simultaneously with, or follow- 
ing the latter. 

The two important factors in the course of the disease 
are paralytic attacks and remissions. The attacks may 
appear at any time during the course, producing an unex- 
pected progress in deterioration or even a fatal termina- 
tion. They may usher in the disease, being followed by a 
condition of advanced deterioration, but more frequently 
occur during the terminal stage. These attacks appear 
•most frequently in the demented and the expansive forms. 


Remissions are most often encountered in the agitated 
and expansive forms and very rarely in the demented 
forms. The improvement which is usually rapid, appears 
only during the earlier stages of the disease. Both the 
physical and mental symptoms show marked improve- 
ment ; the consciousness becomes clear, the content of 
thought coherent, and the delusions and hallucinations dis- 
appear. The patients often look back upon their psychosis 
as a sort of dream without a clear insight. In the course 
of a month or two they may have so far improved that as 
far as limited associations of the institution permit, they 
appear perfectly well. When at liberty, however, it is 
apparent to their friends that they have lost their former 
mental energy, they tire easily, and are changed in dis- 
position. Yet they are usually eager for employment and 
disregard the advice of the physicians to exercise care. 
Some of the patients are able to engage successfully in 
their former occupation and support their families. In 
other cases the remission is only partial, the patients be- 
come clear and coherent, while the expansive and depres- 
sive delusions disappear ; but there still remains a tendency 
to excessive activity, with a desire to enter into uncertain 
business ventures, to be lavish with money, careless in 
personal appearance, and irritable and fretful in disposi- 
tion. The duration of the remission seldom lasts over 
three or four months, but in some cases it extends over 
three years. 

Diagnosis. — In the diagnosis of dementia paralytica the 
essential symptoms are defective memory and attention, 
weakness of judgment, emotional indifference, change of 
moral character with greater pliancy in conduct, and the 
physical symptoms, of which defective pupillary reaction 
is the most prominent. According to Siemerling ninety- 


two per cent, of immobile pupils belong to paretics. Defec- 
tive speech with slurring, inability to arrange syllables and 
words in proper order, and tremor of the facial muscles, 
are almost sure signs of the disease. The apoplectiform 
and epileptiform attacks without residual motor paralysis, 
if epilepsy, alcoholism, uremia, and diabetes can be ex- 
cluded, point to dementia paralytica. 

The disease is distinguished from neurasthenia by the 
absence of insight, failure to carry out medical advice, and 
lack of improvement with simple relaxation. Neurasthe- 
niacs appreciate too keenly their illness, exaggerate their 
symptoms, and at the same time try to alleviate their con- 
dition. They complain of failing memory, which really 
does not exist, while paretics often fail to recognize such 
mental defect. The physical symptoms of neurasthenia 
are confined to dizziness, slight stammering when embar- 
rassed, and fine tremor of the tongue, with increase of the 
tendon reflexes. One should at least think of paresis when 
neurasthenic symptoms appear for the first time in middle 
life without adequate cause. 

The depressive form of the disease is distinguished from 
melancholia of involution by the presence of mental deterio- 
ration, weakness of judgment, moral instability, failure of 
memory, defective time orientation, silliness and incohe- 
rence of the delusions, and presence of physical signs. The 
melancholiac shows a greater prominence of self -accusations 
and infrequent clouding of consciousness, except in cases 
with great prominence of hallucinations and delusions, 
where the differentiation must depend almost entirely upon 
the presence of physical signs. 

The depressive forms of manic-depressive insanity are 
distinguished by the absence of any signs of mental dete- 
rioration and by the presence of retardation among the 


motor phenomena. In the stuporous states the manic- 
depressive patient partially apprehends his surroundings, 
although he takes no part in them ; he shows some anxiety 
and discomfort when interfered with and seldom moves 
voluntarily, while the paretic is unable to comprehend his 
surroundings, fails to heed threatening attacks, and occa- 
sionally moves freely and even restlessly. 

The maniacal forms of manic-depressive insanity are dif- 
ferentiated from the expansive and agitated forms of pare- 
sis by the pressure of activity and the absence of mental 
deterioration. The paretic is unable to recall correctly recent 
events, and especially the date of their occurrence. His 
delusions are more extreme, fantastic, and contradictory ; 
his emotional attitude is variable, and dependent upon the 
surroundings and suggestions. The maniac, on the other 
hand, is more alert and quick in apprehending when his 
attention can be attracted, he shows an acute memory, his 
delusions are less often contradictory, are expressed with 
less assurance and more facetiousness, and he is seldom 
contented and less pliable. 

It often happens that periods of excitement at the onset 
of the disease are mistaken for delirium tremens, especially 
where early paretic symptoms have escaped notice in an 
alcoholic. In the paretic there is a profound clouding of 
consciousness, and an absence of terrifying hallucinations of 
sight and hearing, while the alcoholic presents the charac- 
teristic mixture of anxiety and humor. 

Dementia prwcox is differentiated by the absence of the 
characteristic physical signs, less prominent clouding of 
consciousness, the presence of mannerisms ; and the 
catatonic forms by the stereotyped actions and speech, 
and negativism. The paranoid forms do not show paretic 
inability to comprehend the surroundings, require consider- 


able time for the delusions to equal in expansiveness those 
of paresis, and the coherence in thought is well retained. 

Senile dementia, which is also due to extensive degener- 
ation in the cortex, may be recognized by the age at onset, 
the more prolonged course, comparative poverty of delusions 
and absence of characteristic motor symptoms, excepting 
partial paralysis and apoplectiform attacks, the last of 
which in senile dementia are usually followed by signs of 
motor paralysis, which persist for at least a few weeks. 

Cases of cerebral tumor occasionally run a typical course 
of the demented form of dementia paralytica, the only point 
of differentiation being the cupped optic bisc. Usually brain 
tumors give evidence of focal motor symptoms, and are 
associated with very little mental deterioration. 

Cerebral lues, when not focal and when occurring later 
than ten years after the primary infection, can be dis- 
tinguished from dementia paralytica only with difficulty. 
It usually shows marked improvement under the influence 
of anti-syphilitic treatment, but even this is not a sure sign, 
as the improvement may be only temporary, the disease 
later running a typical course of dementia paralytica. 

The prognosis of the disease is decidedly unfavorable. 
Death occurs in the vast majority of cases within two 
years ; the length of life, however, varies in the different 
forms; a few cases survive five or six years. One case 
of eighteen years has been reported. The immediate causes 
of death are paralytic attacks, pneumonia, and intercurrent 
diseases, sometimes septicaemia following infection from 
wounds, sometimes suffocation caused by food entering 
the air passages ; but the usual manner of death is from 
marasmus and heart failure. The patients become emaci- 
ated, the muscles atrophy, the heart weakens, the pulse 
becomes imperceptible, and life gradually flickers out. 


The treatment of the disease is purely symptomatic, the 
first requisite being forced rest, with the removal from busi- 
ness and uncomfortable surroundings, and the establishment 
of a suitable routine in the physical and mental life. Quiet 
and tractable patients in good circumstances may be treated 
at home, but others require hospital treatment. Suitable 
rest and * relaxation cannot be procured at a fashionable 
health resort with the bath cures, massage, and numerous 
attractions. Next to rest, there should be planned a 
nutritious diet, abstinence from alcohol, coffee, tea, and 
tobacco. Moderate exercise in the open air, and care- 
fully executed hydrotherapy and light massage are of 
great value. The administration of anti-syphilitic treat- 
ment is more often detrimental than helpful. The 
cases of marked improvement claimed to follow its use 
only coincide with the average number of expected remis- 
sions, while in many cases in which there is no improve- 
ment, deterioration seems to be more rapid and profound. 

The conditions of excitement are usually relieved by 
prolonged warm baths, given at a temperature of ninety- 
eight to one hundred degrees, and from one-half to two 
or more hours in duration. In conditions of excitement 
with extreme filthiness, the patients may be kept in the 
bath continuously for some days. 1 

1 Where the warm bath is inaccessible, the cold packs may be substituted, 
which in the hands of several American physicians seems to give excellent 
results. The packs to be effective must be properly applied. The partial 
pack usually suffices to bring about the desired result, applying it to the 
lower extremities, or to the arms. In the whole pack a large and heavy 
woollen blanket is spread upon the mattress, and over it is laid a coarse linen 
sheet, well wrung out in water of a temperature from sixty to seventy 
degrees, so placed that the patient can lie at the junction of the middle, and 
right third of the sheet. When the patient is in position, with the arms ele- 
vated, and provided with a wet turban, the right portion of the sheet is drawn 
across the body and tucked. The arms are lowered to the side and covered 


The conditions of extreme anxious unrest with excite- 
ment seldom yield to any form of treatment. If pro- 
longed warm baths or cold packs fail, one may try large 
subcutaneous injections (one and one-half pints) of normal 
salt solution, which can be repeated twice daily for a 

In the last stages of the disease, extreme cleanliness is 
the essential requisite. It is only by this means that bed- 
sores can be avoided. The bed-clothing must be kept dry, 
clean, smooth, and free from crumbs, and the body fre- 
quently cleaned with cold water and alcohol. Frequent 
changes of the position of the body prevent the occur- 
rence of hypostatic pneumonia. Acute decubitus, once 
formed, is very obstinate and should be treated surgically 
as an ulcer. The nourishment in this stage must be 
liquid, in order to prevent choking. Daily observation 
of the condition of the bladder and bowels is also neces- 
sary. Finally, the mouth should be kept thoroughly 
clean. The paralytic attacks may yield to ice packs on 
the head or to amylene hydrate (thirty to sixty min- 
ims) or chloral hydrate, the former of which may be 
given by subcutaneous injections in a five to ten per cent, 

with the left portion of the sheet, which is drawn across the body and securely 
tucked, especially about the neck and feet. The patient is then covered with 
several woollen blankets. The duration of the pack should be from one-half 
to one hour, and may be followed by brisk rubbing with alcohol. The dura- 
tion of the partial pack may be more extended than that of the whole pack. 
When the patient falls asleep in it, it is not necessary that it be removed 
until he awakes. There is no harm in an immediate renewal of the partial 
pack. It should be remembered in the application of these partial packs, as 
well as in the whole packs, that all air must be excluded from in under the 
cover of woollen blankets, for which purpose many use a final covering of 
rubber cloth or oil silk. 



Voisin, Traite* de la paralysie generale des alienes, 1899. 
Mendel, Die progressive Paralyse der Irren, 1880. 
Mickle, General Paralysis of the Insane, 2d edition, 1886. 
Krafft-Ebing, Nothnageis specielle Pathologie u. Therapie, Bd. 9, 

2, 1894. 
Ilberg, Volkmanns klinische Vortraege, 161. 


The psychoses arising from organic disease of the brain 
are described under two divisions according as the lesions 
are diffuse or localized. 

Diffuse Lesions 

Fuerstner has described a condition of gliosis of the 
superficial layers of the cortex with cyst formation and 
atrophy of the nervous elements, which clinically is rep- 
resented by infantile convulsions or imbecility, and a pro- 
gressive mental deterioration with weakness of memory, 
speech disturbance, optic atrophy, and even tabetic 

Besides the diffuse sclerosis of the brain, with progres- 
sive mental deterioration, hemiplegia, convulsive attacks, 
increase of the patellar reflexes and spasms, Homen 1 has 
called attention to a condition similar to the demented 
form of paresis in children of the same parents, called 
delayed hereditary syphilis. In it there is extensive 
endarteritis, and atrophy of nerve fibres, especially in 
the frontal lobes, slight changes in the cell bodies, and 
an increase of neuroglia. 

Alzheimer 2 and Binswanger 3 designate as arterio- 
sclerotic insanity, a psychosis characterized by gradual 
development with headache, vertigo, irritability, loss of 

1 Archiv. f . Psy., XXIV, 1. 

3 Berlin, klin. Wochenschr., 1894, 49. 
8 Allgem. Zeitschr. f . Psych. LI, 809 ; ebenda, LITE, 863. 



memory, and stupidity, and many remissions with transi- 
tory periods of brightness and normal behavior even in 
dementia; physically by disturbances of speech, both 
paretic and aphasic, and frequent circumscribed paralyses. 
It appears from the fortieth to the fiftieth year. The 
vessels present diffusely, sometimes also in circumscribed 
areas, thickened walls, dilated lumina, many miliary aneur- 
isms, and capillary hemorrhages, and there is an increase 
of neuroglia, and degeneration and atrophy of the cortical 
neurones. Arteriosclerotic changes in the other organs 
are prominent. 

Binswanger has also described encephalitis subcorticalis 
chronica progressiva, which appears in senility, involves 
especially the posterior portions of the cerebrum, and is 
characterized by an atrophy of the corona radialis with 
dilatation of the ventricles. Clinically there is progres- 
sive dementia with many persistent focal lesions. 

The mental condition accompanying multiple sclerosis 
depends upon the diffuseness of the process. In the diffuse 
lesions there are general progressive mental deterioration 
and confusion or excitement, as well as nystagmus, inten- 
tion tremor, and scanning speech. 

Localized Lesions 

Of the localized brain lesions, the most important are 
tumors, abscesses, hemorrhages, emboli, and thrombi. 

In large brain tumors the mental symptoms are more 
apt to depend upon the intracranial pressure, and as such 
consist of dulness, a certain insensibility, and apathy which 
increases to lethargy. If the tumor is of slow growth, 
causing disintegration rather than displacement, the mental 
symptoms may be very slight until near the end. 


Cerebral abscess of gradual development may be un- 
accompanied by any mental symptoms until far advanced, 
when stupor appears with or without convulsive attacks. 
In more rapid cases of traumatic character, stupor is the 
most prominent symptom, in which there may be some rest- 
lessness, resistance, or delirious behavior with incoherent 
speech, sometimes associated with aphasia, slow pulse, 
Cheyne-Stokes respiration, and epileptic attacks. 

The mental disturbance accompanying cerebral hemor- 
rhage or embolism at the time of the insult is one of clouded 
consciousness with disorientation and confused actions, 
sometimes accompanied by motor resistance and loud 
talking or outcries. When the patients become oriented 
and quiet, the memory is found to be defective, espe- 
cially with reference to the time of occurrence of events 
of their former life. Many are quite unable to calcu- 
late time. Besides this, there is frequently failure of 
memory for certain definite groups of ideas, as, for proper 
names and numbers. It is often very difficult to estimate 
the mental capacity of patients, because of aphasic or 
paraphasic disturbances. Patients of good mentality are, 
for this reason, sometimes considered imbecile. Extensive 
lesions in the cortex produce general mental enfeeblement 
with dejective judgment and difficulty and slowness of 
thought. Occasionally ideas of persecution appear. In 
emotional attitude there is a great tendency to fluctua- 
tion; at one time the patients are lachrymose, petu- 
lant, and quarrelsome, at others careless, indifferent, and 
even stupid. Besides showing a constant tendency to 
excitability, they may also present transitory periods of 
motor excitement, with great talkativeness and expansive 
ideas. These latter states are often associated with 
postapoplectic and epileptiform attacks. Moral obtuse- 


ness becomes evident in the lack of regard for the family 
and social customs, as well as the great selfishness and 
lack of interest in matters which formerly most concerned 
them. The patients may begin to drink, loaf, and squander 
their property. 

A considerable group of cases of mental disturbance 
follow head injury. Insolation is regarded as a form of 
head injury. The immediate result of severe cerebral con- 
cussion is apt to be a condition of unconsciousness, which 
may last from a few hours to several weeks. In this state 
the patients are completely disoriented, without memory 
for passing or previous events, or at most, a very vague 
memory, and show a marked tendency to fabrication. 
Thought is slow and difficult. They are usually irritable, 
emotional, sometimes talkative, and often restless. There 
is no insight. 

The secondary effects appear as a permanent change in 
the personality. Following the injury, there may be no 
striking symptom except that the man is changed. This 
alteration may consist of unusual fatigue upon slight 
exertion, forgetfulness, inattention, unwonted timidity, 
moderate depression, and a tendency to irritability which 
may extend even to an exhibition of passion. There is 
almost always increased susceptibility to alcohol. Peri- 
odical exacerbations of the symptoms is a striking feature. 
Among the nervous symptoms the most prominent are 
convulsions, irresponsive or unequal pupils, deviation of 
the axes of the eyes and of the tongue, and defective 

Difficulties in diagnosis arise in most of these different 
mental disturbances, especially in differentiation from 
dementia paralytica. The etiological factors, the character 
of the onset, the clinical course of the psychosis, and the 


character of the nervous symptoms are the most important 
aids in the diagnosis. Symptoms indicative of a circum- 
scribed lesion do not point to paresis. Brain tumor is occa- 
sionally mistaken for hysteria. 

The treatment is of little avail except in syphilitic focal 
lesions, abscesses, and a few cases of tumor, and also in 
traumatic psychoses with depressed fracture of the cal- 
varium, or with the formation of hsematoma of the dura. 
Success in traumatic cases depends in great part upon the 
time of operation. If some time is allowed to elapse, im- 
provement following operations is only transitory. 


The three forms of mental disease, melancholia, pre- 
senile delusional insanity, and senile dementia, described 
as involution psychoses, seem to stand in a causal relation- 
ship to the general physical changes accompanying invo- 
lution. The relationship is quite apparent in senility, but 
such changes may become evident in the characteristic 
mental disturbances occurring as early as the fifth decade. 
Naturally there is no distinct border line between the 
period of evolution and involution. The mental disturb- 
ances of the period of involution, used in a narrow sense, 
are always, in spite of many symptoms in common, of a 
somewhat different stamp than those characteristic of old 
age. Those occurring in the former period are called 
melancholia and presenile delusional insanity, and the lat- 
ter senile dementia. 


Melancholia is restricted to certain conditions of mental 
depression occurring during the period of involution. It 
is to be distinguished from the melancholia of some other 
writers, who apply the term to any condition of depression, 
whether it enters into the picture of dementia paralytica, 
or is a premonitory symptom of acute delirium, or accom- 
panies hysterical insanity, etc. In this broad sense it 
simply expresses an emotional state. Melancholia, as 
applied here, represents two groups of cases, which are 



characterized by uniform depression with fear, various 
delusions of self-accusation, of persecution, and of a hypo- 
chondriacal nature, with moderate clouding of conscious- 
ness and disturbance of the train of thought, leading in 
the greater number of cases after a prolonged course to 
moderate mental deterioration. 

Etiology. — The disease should be regarded as one of 
the evidences of beginning senility. The majority of cases 
occur between the ages of forty and sixty. It seldom 
occurs under forty or over sixty. Sixty per cent, are 
women. In women the disease appears a little earlier, 
seeming to bear a relation to the climacterium, while in 
men the onset is later. Defective heredity occurs in a 
little over one-half of the patients. External influences, 
such as mental shock, the loss of friends, illness from 
acute and chronic diseases, and surgical operations, seem 
to play a rather important part as exciting causes of the 

Pathological Anatomy. — The anatomical changes which 
have thus far been noted are only those of arterio- 

Symptomatology. — The First Group of cases is the more 
common. Prodromal symptoms very often exist for many 
months, of which the most prominent are persistent head- 
ache, vertigo, indefinite pains, general debility, loss of 
appetite, constipation, palpitation of the heart, and in- 
creasing difficulty with work. 

The onset is gradual, extending through months and 
sometimes even years. The patients become sad, dejected, 
and apprehensive, and find no enjoyment in their work or 
home environment. They are overpowered by doubts, 
fears, and self-accusations, refusing to be consoled by 
friends. They feel ill, complain of being dumb, confused, 


and forgetful, and find it difficult to do anything. During 
this period there are occasional days when they are free 
from apprehension and sorrow. 

Delusions of self-accusation become prominent. Patients 
become retrospective, many misdeeds are referred to in 
going over their past life, which are held as an adequate 
basis for their depression. These retrospective self-accusa- 
tions form a prominent symptom. Remote and often in- 
significant facts are recalled, such as the stealing of fruit 
in childhood, disobedience to parents and neglect of friends, 
which now cause them the greatest anxiety. They are 
perfectly wretched about it. Their whole life has been 
made up of similar misdeeds. A patient was miserable 
because she had requested her sick sister to remain out of 
the kitchen ; another because at the death of her mother 
she had allowed herself to think of and mention the 
division of property. Many refer to former sexual indis- 
cretions. These references vary from day to day, or may 
be maintained with great firmness for a long time. 

A religious strain is very prominent in many. They 
are wretched because they are not as fervent in prayer 
as formerly ; they no longer possess real religious feelings, 
or have sinned against the Holy Ghost. The patients 
reproach themselves for everything ; they cannot do any- 
thing right. Everything in the environment is a source 
of special anxiety to themselves; the lamentations of a 
fellow patient are directly the result of their own mis- 
deeds, others want for food if they eat. 

Other delusions of fear are those of punishment for 
past misdeeds. The patients believe themselves damned 
by God ; they will be turned out of their home, brought 
to court, thrown into prison, or killed outright. People 
are waiting outside to carry them off, the death warrant 


is already signed. There is no need of taking food. 
They would rather starve and suffer for their misconduct, 
and even ask to be put out of the way. Sometimes they 
even exaggerate their misdeeds and confess crimes which 
they have never committed, in order to secure severer pun- 
ishment and obtain relief for their guilty consciences. 

In other cases the delusions are hypochondriacal in 
nature. Patients insist that they are the most unfortu- 
nate individuals in the world; the stomach is gone, the 
lungs are filled up, shrunken, and all sensation lost. The 
brains and nerves are rotting away as the result of former 
sexual abuse. They fear that they are dying of consump- 
tion or cancer, and that they are going out of their minds 
and must end their days in an asylum. They maintain 
that the body has been poisoned, banishing all appetite, 
and now they must starve. They also express consider- 
able apprehension for themselves and families; they will 
be deprived of their home, some great calamity will visit 
them, the children will die, or they themselves will be 
robbed and killed, will be driven from the church and 
damned by God. 

These depressive delusions so thoroughly influence their 
actions that they become seclusive, eat sparingly or not 
at all, refuse to spend money, and clothe themselves and 
their children scantily. They give up everything because 
they have only a short time to live. Hallucinations of 
hearing and sight accompany this condition, but they are 
usually indefinite and of short duration. The conscious- 
ness is usually clear. The patients are mostly well 
oriented. They may, however, fail to recognize where 
they are, claiming that they are in a prison, and they may 
mistake strangers for acquaintances, but in spite of this 
it may be readily seen that they comprehend well. 


Thought is coherent and relevant, but the content is 
usually centred about the depressive ideas, to which they 
always recur with great frequency, recounting their mis- 
deeds and the dreadful things to happen. Very often 
they show a tendency to repeat certain phrases, as " Let 
me go home, let me go home ; I want to see my children, 
I want to see my children." There is usually some insight 
into their illness, the patients complaining that their head 
is not right, and readily submitting to treatment, but at 
the same time failing to recognize many symptoms of the 
disease as such. 

In conduct the patients show a certain constraint and 
lack of freedom in movements, but are not uniformly 
retarded, as in manic-depressive insanity. They may be 
indolent, sitting for hours, and even days, with folded 
hands, or keeping to bed. Very many are restless, 
attempting to remain at work and to busy themselves 
in order to drive away their bad feelings. The counte- 
nance is sad, the figure loses its elasticity. The voice 
may be low and feeble, and the individual movements are 
rather listless. Attempts at suicide are frequent in this 
form, and very often are the result of deliberation, but 
with a few they come as an impulse. 

The Second Group of cases is characterized by a greater 
predominance of delusions of fear, which are apt to be 
extremely silly, and sometimes even nihilistic, many hal- 
lucinations, great clouding of consciousness, and some motor 

The prodromal symptoms and the onset are usually 
similar to those of the first group. The onset may be 
more rapid, especially in cases with prominent exciting 
causes. The slight depression soon gives way to extreme 
dejection. The patients accuse themselves of horrible 


crimes, which have led to their banishment or to threatened 
execution : have murdered their husbands, devoured their 
children, have brought sin upon the whole world. All 
wickedness is due to them, they have desecrated the 
communion bread, or have spat upon the image of Christ. 
They are totally unworthy, should be buried alive, no one 
should speak to them, hanging is too good, and they should 
be thrown into molten metal. External associations enter 
into and play an important part in their misery. Things 
about them seem unnatural and have a gloomy aspect, 
passing carriages are regarded as a funeral procession, 
the tolling of the church bell indicates that some one 
has died. A spoon lying on the table means that medi- 
cine has been taken, and some one is now at the point 
of death. Hammer and nails found on the floor mean 
that a scaffold is being secretly built for their execution. 
Everything is awfully changed to them, friends and 
relatives are different, the sun and the moon do not 
shine the same, and the house is transformed into a 
dungeon. The end of the world has come, they are now 
to be passed into a lion's den. The hypochondriacal ideas 
are apt to be extremely absurd. The patients claim that 
they have no breath, the blood has stopped circulating, the 
eyes are rotting away, maggots are crawling under the skin, 
and the brain is solid rock. 

The depressive delusions in some cases become nihilistic 
(delire de negation), when the patients claim that nothing 
exists, there is no more food, no more houses, no more trees, 
no cities, no day or night, no sun or moon, no one is alive. 
They are alone in the universe as there is no world. They 
themselves have no name, no wife, no children. They can- 
not eat, cannot speak, cannot die. Occasionally sexual 
delusions of a silly character are present, the patients 


maintaining that they have been outraged at night, are 
now in a house of ill repute, or surrounded by men dis- 
guised as women. These depressive delusions are definite, 
coherent, and usually well retained. There are a few cases, 
especially those with progressive mental deterioration, in 
which a few expansive delusions appear. 

Hallucinations of both hearing and sight are very promi- 
nent. Voices are heard, the devil speaks to them, strangers 
call them names and blaspheme, and bells are heard. 
Patients hear the evil thoughts of others, they see 
strange forms beside them at night, moving bodies and 
spirits. Occasionally they detect strange odors and tastes 
in food, and smell vapors at night. 

Consciousness in this group of cases is usually much 
clouded, showing disorientation for time, place, and persons. 
The train of thought shows confusion, and is limited to 
various delusions, in the expression of which the patients 
are apt to show considerable repetition. Sometimes single 
phrases are repeated for hours, as "What did I do? what 
did I do ? My God ! my God ! " It is sometimes sur- 
prising, however, to find that they are able to answer 
questions coherently, and to clearly describe their symp- 

The emotional attitude is uniformly one of depression. 
The basis for this emotional depression seems to be fear, 
a feeling of oppression, and inner anxiety. Some patients 
claim that it is as if a heavy weight was upon the chest. 
They are timid, uneasy, and feel as though homesick. The 
fear is increased by association with those who are ac- 
customed to arouse in them the deepest feelings, while 
strangers and new environment create little emotional 
reaction. Emotional outbreaks may be present at times, 
when the patients are greatly agitated, and may even 


present a dreamy disturbance of consciousness. These fre- 
quently follow visits of relatives or some unusual occur- 

In conduct the patients are restless and agitated, bewail- 
ing their misfortune, wringing their hands in agony, or pac- 
ing the floor. In their anguish some beat themselves, pull 
out their hair and pick at their finger-nails. Others groan 
and tremble, constantly repeating over and over single 
phrases, as " Tell me what shall I do, what shall I do ? n 
In this condition they have no time nor desire for eating. 
The attire and general appearance are entirely neglected. 
The frequent attempts at suicide are here more often the 
result of impulse, in the accomplishment of which some 
fairly hack themselves to pieces ; one woman reduced her 
scalp to pulp with a hammer, fracturing her skull 
in several places, and without any regard for pain; 
another devoured the ends of sulphur matches. Some 
of the patients are more composed, and are able to sit 
or lie quietly most of the time, only occasionally rising 
to gaze about them in fear or perplexity. While the 
individual movements are often slow, they are not uni- 
formly retarded, as the patients are able to execute orders 
readily and quickly. A few cases present symptoms similar 
to those in the catatonic form of dementia praecox, such 
as stupidity, constrained positions, catalepsy, and echolalia ; 
while true negativism, stereotyped movements, mannerisms, 
and impulsive actions are rarely encountered. 

Physical Symptoms. — The sleep is scanty, disturbed by 
dreams, and unrefreshing. The nutrition suffers and the 
weight sinks. Appetite is poor and digestion is de- 
fective, the bowels are very sluggish, the tongue is 
coated, and the breath foul. The mucous surfaces are 
anaemic. There are apt to be numerous subjective sen- 


sations about the heart, such as palpitation, uneasiness, 
and a feeling of pressure. Circulatory disturbances are 
often present, as cyanosis, coldness and edema of the 
limbs. The pulse may be small and irregular or slow, 
and the arteries may give evidence of beginning sclerosis. 
Other changes indicative of senility are sluggish reaction 
of pupils, grayness of the hair, cessation of the menses, 
dryness and harshness of the skin. 

Course. — There is a gradual development, a prolonged 
duration, and a still more gradual convalescence. In cases 
of recovery the whole course lasts at least twelve months 
to two years. Short remissions, during which there is 
only a partial disappearance of the symptoms, occur 
throughout the whole course. Exacerbations often arise 
as the result of annoyance, fatigue, and excitation, such as 
that induced by visits. A gradual improvement of the 
physical symptoms, especially an increase in weight, may 
be regarded as a favorable sign. The remissions become 
longer and more marked, and the apprehension gives way 
to irritability and fretfulness ; the patients then begin to 
display interest in work and reading. Even when con- 
valescence is well established, it is not unusual for them 
to have " bad days," during which they are troubled and 

Diagnosis. — The greatest difficulty arises in distinguish- 
ing those cases of the depressive form of manic-depressive 
insanity which appear for the first time in involution. The 
essential difference is found in the psychomotor condition. 
In melancholia the actions are all the natural expression of 
the anxious and irritable state of the emotional attitude, 
while in the depression of the manic-depressive patient 
there is retardation and slowness of involuntary move- 
ments. The irritability of the melancholiac expresses an 


inward anxiety, but the occasional irritability of the 
manic-depressive is accompained by some pressure of 
activity in conduct and speech. 

Considerable trouble maybe experienced in differentiating 
dementia paralytica. In melancholia one finds a subacute 
onset following definite prodromal symptoms ; greater or 
less clouding of consciousness, a more consistent emotional 
attitude, and absence of evidences of mental deterioration 
early in the disease, while in dementia paralytica there is 
a gradual onset with early evidence of mental deteriora- 
tion, defective time orientation, poor judgment and memory, 
silly and contradictory delusions. Furthermore, the emo- 
tional attitude does not always correspond with the ideas 
expressed, and consciousness is more deeply clouded. 

Prognosis. — The prognosis is not favorable, considering 
that only one-third of the cases recover, the remaining 
two-thirds undergoing mental deterioration. However, 
at least one-half the cases improve so as to be able to 
return home and live comfortably, sometimes aiding in 
the maintenance of the family. Almost one-quarter die 
of intercurrent affections, mostly tuberculosis, within two 
or three years. The patients, being apathetic and anergic, 
taking little exercise and insufficient food, become more 
and more emaciated, and finally succumb to some infec- 
tious or chronic disease. The prognosis is less favorable 
over fifty-five years of age. 

In those who improve, but do not recover, the depres- 
sion with the delusions disappear, and the consciousness 
becomes perfectly clear, but the patients fail to develop 
interest in the surroundings and to adapt themselves to 
any kind of work. They are dull, stupid, and indifferent. 
Others, who show deeper deterioration, after the disappear- 
ance of the marked delusional state, fail to gain insight 


and to recover coherence of thought. They are forget- 
ful, apathetic, and entirely unable to apply themselves. 
Residuals of former delusions as well as a few hallucina- 
tions and some expansive ideas remain. Indications of an 
unfavorable outcome appear when the depressive give way 
to expansive delusions. These are rather scanty and weak. 
The patients believe that they have become wealthy, have 
been endowed with some special powers, have been called 
of God, and can heal disease. These ideas rarely influence 
the conduct to any extent. The patients sometimes regard 
those about them as important personages. Other favor- 
able changes are abatement of the excitement with reten- 
tion of the delusions, and the appearance of silliness, while 
depressive ideas are maintained. Fifteen per cent, of the 
cases which recover tend to recur, but in these the first 
attacks are very light. 

Treatment. — The first essential is the establishment of 
a "rest cure," which should include the removal of the 
patient from irritating persons as well as objects. It is 
necessary in most cases that the patients be confined in 
bed with short intermissions, with sufficient and constant 
attendance. In very light cases a suitable change may be 
found in removal to a different boarding-place or into the 
associations of a happy family. It is decidedly not advis- 
able to attempt distractions, such as might be afforded by 
long journeys, sight-seeing, and constant company. 

Next to forced rest in bed comes nutrition. The food 
should be nutritious, given in small quantities and at fre- 
quent intervals. Monotony in diet should always be 
avoided by consulting the tastes of the patient. Careful 
regulation of the intestines usually improves the appetite. 
Extreme anxiety and restlessness often necessitate artificial 
feeding by stomach or nasal tube in order to maintain nutri- 


tion. Insomnia, which is troublesome and often difficult 
to overcome, is best relieved by warm baths (ninety-eight 
to one-hundred degrees), which may be prolonged for an 
hour. These measures, well carried out, often render 
hypnotics unnecessary, the use of which is always in- 
advisable because of the prolonged course of the disease. 
Of the hypnotics alcohol is the most valuable. Of the 
other hypnotics, sulfonal and trional in ten to fifteen 
grain doses, the bromides, or paraldehyde one-half to one 
fluid dram are the most useful. Hot malted milk before 
retiring may aid in inducing sleep. 

The distressing condition of anxious restlessness may be 
combated with opium or morphin in increasing doses. It 
should be given in rapidly increasing doses, even reaching 
fifty to sixty drops of the tincture of opium three times 
daily, which is later gradually reduced, as the restlessness 
subsides. This drug sometimes not only fails, but serves 
to aggravate the symptoms. Improvement from this 
source, if it is to occur, appears rapidly. Suicidal ten- 
dencies necessitate careful and constant watching, as 
melancholiacs are the most difficult to thwart in their 
attempts at suicide. This care must be as strenuously 
observed until recovery is established. The rest in bed 
should not be too prolonged; later it is best that it be 
gradually replaced by short drives or walks, combined with 
daily change of scenery. 

The psychical influence which may be constantly exerted 
over the patients by those in attendance is of the greatest 
value in alleviating distress, modifying the delusions, and 
relieving the anxiety. For this reason the manner should 
be gentle, friendly, and assuring, and attempts should 
always be made to lead the thoughts of the patient away 
from their depressive ideas. Visits from relatives are 


deleterious in the height of the disease. Finally, it is of 
utmost importance that the patients be kept under observa- 
tion and treatment until thoroughly recovered. A safe 
index of this may be found in the insight into the disease 
and the return of sleep and nutrition to their normal 


Krafft-Ebing, Die Melancolie. 

Christian, Etude sur la Melancolie, 1876. 

Voisin, De la Melancolie, 1881. 

Roubinowitsch et Toulouse, La Melancolie, 1897. 

Ziehen, Erkennen und Behandlung der Melancolie in der Praxis, 

Kraepelin, Die klinische Stellung der Melancolie, Monatschr. f. Psy. 

u. Neur., Bd. 6, S. 325. 
Hoch, Melancholia; Reference Handbook of Medicine, 1902. 


There is a small group of cases appearing during invo- 
lution which are unlike either melancholia or senile de- 
mentia, partaking more of the characteristics of dementia 
praBcox. It has been tentatively differentiated and charac- 
terized by the gradual development of marked impairment 
of judgment, accompanied by numerous unsystematized, 
hypochondriacal, and persecutory delusions, and greatly 
increased emotional irritability. 

Etiology. — The psychosis is rare, occurring only twelve 
times in ten years' experience. The majority of the cases 
are women, in whom the disease appears between fifty-five 
to sixty-five years of age; while in men it occurs about 
the fiftieth year. There seems to be marked hereditary 
predisposition to the disease. As no other reasonable 
cause can be assigned, it is assumed that we have to 
do with a disease of premature senility on the basis of a 
morbid predisposition. 

The fact that the persecutory delusions of the genuine 
senile presents many similarities supports this view. How- 
ever, a more extended experience is necessary to determine 
if this is a particular disease process. 

Symptomatology. — The onset of the disease is gradual, 
with a change of disposition. The patients at first become 
quiet, seclusive, discontented, moody, suspicious, and irri- 
table. Delusions gradually appear which at first are quite 
vague and transitory, but later become more persistent 
and assume definite form. Among the first delusions to 



arise are those of a hypochondriacal nature. The patient 
complains of the most varied and changeable nervous sen- 
sations and pains, spasmodic twitchings, vertigo, troubled 
dreams, debility, malaise, roaring in the ear, etc., remind- 
ing one very much of hysterical complaints. These ideas, 
however, usually become more senseless, when the patients 
state that the spine is dried up, the brain shrunken, and 
all strength departed. 

Other delusions apt to appear are those of persecution, 
which often are quite fantastic. The patients claim that 
their clothing has been exchanged or stolen ; that articles 
of furniture have been removed and others of less value 
substituted. There are thieves about. They suspect 
poison in the food ; accuse the physician of trying to get 
rid of them, of behaving in an obscene manner, of remov- 
ing the womb, or making them ill for the purpose of 
studying the case. The husband believes that the wife 
is dosing him secretly. One patient had her sofa taken 
apart because there was some one concealed in it who 
wanted to blow up the house. 

Delusions of infidelity are apt to be a very prominent 
feature. The husband is accused of eyeing women on the 
street, of flirting with every one he meets, of caressing the 
servant, and receiving letters from the schoolmates of his 
daughter. He arranges to meet women whenever he 
leaves home, and has intercourse with every one possible. 
The husband is suspicious of his wife because she leaves 
him at night, and seems surprised and alarmed upon his 
return home. 

It is characteristic of all these delusions that they are 
exceedingly unstable. They spring up at one moment, 
are abandoned in the next, and again recur in another 
form. Many patients admit that they might have been 


mistaken and that they are sick, but in reality they fail 
to appreciate the senselessness of their ideas. Perhaps a 
half-hour later you will find them in the greatest distress 
because they have been poisoned, or because some one has 
hidden under the bed. They surely will die ; a peculiar 
feeling about the heart indicates that their son must be 
dead. A soothing word usually suffices to quiet them and 
dispel all apprehension. 

Hallucinations accompany the delusions in only a few 
cases. The patients perhaps are threatened, or hear 
strangers boast of intercourse with their wives. The 
cries of their ill-treated children reach them. At night 
they may see dark forms stealing out of the room, or 
feel some one lying beside their wives. It is a noteworthy 
fact that the patients do not make further attempt to 
intercept the guilty parties. If a search is instituted and 
they fail to find any one, they simply express anger because 
connubial infidelity was violated with such shamelessness 
and slyness in their own presence. 

Consciousness is unclouded and orientation unimpaired. 
Thought is coherent, but judgment shows a marked weak- 
ness, noted in the retention of the most fantastic delusions, 
while the consciousness of the patient is perfectly clear. 
He cannot see the senselessness of the delusions ; while 
he allows himself to be persuaded, he cannot be convinced. 
The memory for remote events is unimpaired. However, 
in his narration of his delusions, he adds all sorts of em- 
bellishments and misrepresentations. 

The emotional attitude at first is one of depression and 
fear; occasionally it leads to suicidal attempts. Later 
there usually appears some excitement and irritability. 
The patients then talk a good deal, make verbose com- 
plaints, stir up boisterous scenes, fly into violent passion, 


and are abusive, but they are usually quieted without 
difficulty. They sometimes laugh and cry without 

The conduct is characterized by all sorts of senseless 
actions. In accord with their delusions many patients 
run about from one physician to another, and solicit much 
advice without attempting to follow any of it. Some 
stop eating, withdraw from their associates, destroy every- 
thing within reach, and become violent. Jealousy leads 
to strict surveillance of the husband or wife. The servant 
is sent out in the search of them; torn letters in the 
waste basket are placed together in order to obtain proof 
of guilt, and the supposed seducers may be publicly 
accused. One patient went to the police to have a young 
unmarried lady placed under surveillance. 

Course. — With the advance of the disease the delusions 
become more senseless ; the patient claims that the wife 
and children are being tortured, the son nailed to the 
floor, or suspended on a fence. Nightly the wife wan- 
ders about from one place to another, and every one talks 
about it. Female patients believe that their husbands 
have intercourse with their own children, and even with 
other men, disguised as women. They become aware of 
this by sensations in their own body whenever they are 
deceived. The precious Lord proclaims everything, speaks 
to the patients, lies near them in bed at night like a 
shadow; Persons and environment are changed; their 
own bodies are disfigured and influenced. Many patients 
for that reason remain in seclusion, veil themselves, some- 
times refusing to speak and then suddenly becoming very 
friendly and communicative. These delusions change fre- 
quently, even temporarily falling into the background, 
although some general signs of them are constantly re- 


curring. But in spite of progressing mental deterioration, 
the patients do not become incoherent. 

Diagnosis. — By some these cases might be regarded 
as paranoia, but they certainly differ from paranoia, in 
that the delusions are not systematized and there is no 
attempt made to trace their origin to a definite source. 
The persecutors remain indefinite or change frequently, 
and the suspected consorts are not regarded as enemies, 
but are frequently considered as having been seduced. 
Moreover, the patients do not establish any broad basis 
for action from out of their delusions, and except for 
their occasional violent outbreaks, they do not treat 
the supposed persecutor as especially hostile; they as- 
sociate with their faithless wives, in fact even force 
themselves into their company, and they quickly become 
agreeable and friendly toward those persons whom they 
have just previously suspected and accused. They often 
like to remain in the hospital in spite of complaining of 
all sorts of persecution, and take pleasure in protection 
which is afforded them there. Finally, the delusions do 
not continue stable, but change frequently and sometimes 
even in a short time. Their conditions of excitement 
seem to depend less upon deliberation than their emo- 
tional vacillations. 

By others this group of cases might be considered as 
belonging to dementia praicox, which undoubtedly occurs 
at this age, although not frequently. The only consider- 
ation against this view is the fact that the patients do not 
present catatonic symptoms. The resistance, mutism, 
refusal of food, and excitement, occasionally manifested, 
are not simply compulsive or instinctive, but depend upon 
the delusions or the moods. There is no emotional 
obtuseness ; on the contrary, the patients continue irri- 


table while disturbances of judgment greatly predominate 
over that of the emotions and actions. 

Prognosis. — The outcome is never characterized by 
profound dementia or confusion of speech, but by a mod- 
erate deterioration, with isolated, changeable, and incohe- 
rent delusions. Recoveries or marked improvement are 
not likely to occur. 

Treatment. — There is no special method of treatment 
applicable here. Many patients who are a source of 
trouble outside need hospital treatment, in which case 
neither the discipline nor the lack of freedom encountered 
there cause them annoyance. Some patients are able 
under favorable conditions to remain at home. 


Senile dementia includes those forms of mental disease 
appearing in the period of involution, depending upon 
sclerosis of the brain, the primary and fundamental symp- 
tom of which is progressive mental deterioration. 

It appears in three forms, simple senile deterioration, 
senile confusion, and senile delirium. A single case in its 
course may present the picture of any one or all of these 

Etiology. — The disease may appear at any time during 
involution, but is encountered most frequently between 
sixty and seventy-five years of age. It occasionally 
makes its appearance after some acute disease or mental 
shock. Defective heredity occurs in about fifty per cent, 
of cases. The most important etiological factor is mental 
and physical overexertion with indulgence in excesses. 

Pathological Anatomy. — All advanced cases of senile 
dementia present, both macroscopically and microscopi- 
cally, atrophy of the nerve substance. The brain weight is 
from two hundred to five hundred grams below normal. 
There may be compensatory thickening of the cranium. 
The cerebrospinal fluid is usually increased, produc- 
ing what is called hydrocephalus ex-vacuo. The dura is 
usually adherent to the calvarium. The Pacchionian 
granulations are increased in size. Pachymeningitis 
interna hemorrhagica is often present, and sometimes to 
an extreme degree. The pia is somewhat thickened uni- 
formly over the entire cortex, contains many corpora amy- 

t 273 


lacea, and is almost always edematous. The convolutions 
are narrow and shrunken, and the gaping fissures are filled 
in with edematous pia. Minute hemorrhages are often 
found in the cortex and frequently in the corona radialis 
and basal ganglia. Foci of softening are often present 
in the cortex. In the corona, basal ganglia, and espe- 
cially in the lenticulate nucleus, there is a degeneration of 
the nervous tissue about the vessels, which, with edema, 
gives rise to a spongy appearance, called etat crible. The 
ventricles are much dilated and ependymal wall thickened, 
but rarely granular. The choroid plexuses usually pre- 
sent various stages of cytic degeneration. The cerebral 
arteries exhibit arteriosclerosis with miliary aneurisms. 
These arterial changes may be either diffuse, or may in- 
volve any one of the smaller or larger arteries entering 
the cortex and the subcortical substance. The sclerosis 
of the nervous tissue is intimately associated with these 
arteriosclerotic changes. 

Microscopically, there is an atrophy of the cortical neu- 
rones and a proportionate diminution in the volume of the 
fibres in the corona. The neurones of all layers are in- 
volved. In the cell body the pathological change most 
frequently encountered is the chronic change of Nissl 
(Figure 6, Plate 4) . The cell body becomes shrunken, the 
Nissl granules staining deeply ; the achromatic substance 
also takes on the stain, becoming ill defined, the nucleus is 
elongated, sometimes triangular, its contents being stained. 
The processes of the cell become narrow, tortuous, and 
threadlike. The neuroglia cells are much increased in 
number. The physiological increase of the yellow pig- 
ment in the cell bodies, accompanying advancing age, 
here goes on to a pathological condition in many cases, 
comprising pigmentary degeneration. The spinal cord 


presents a similar atrophy in its ganglia cells and fibre 
tracts. Calcareous placques are sometimes found in the 

The other organs of the body present senile atrophy 
and arteriosclerotic changes. The condition of the heart 
with chronic endocarditis and fibroid changes in the myo- 
cardium is of importance, as it interferes with cerebral 

Symptomatology. — Simple Senile Deterioration. — Se- 
nility brings with it, for every one, a certain degree of 
mental and physical deterioration, so that the border line 
between physiological senility and the state of mental 
alienation cannot always be a sharp one. Of the individ- 
ual symptoms, failure of memory of recent events is the 
most prominent. The patients forget where they have 
placed things, fail to realize that they are repeating the 
same remarks that they made yesterday or a few hours 
ago, forget and cannot recall the names of recent acquaint- 
ances. The present seems to pass without leaving a trace. 
Defective attention is in part accountable for this. The 
patients are also unable, on this account, to follow the 
trend of anything read or spoken to them, and overlook 
details. Almost nothing new is acquired, which leads to 
a dearth and similarity in the content of thought. The 
memory for events of early life is well retained, which 
in advanced cases forms the entire content of voluntary 
speech. Gaps of memory are very often made good by 
fabrications, when all kinds of fictitious events are men- 
tioned, the existence of which for the patients immediately 

There is a progressive defect of apprehension. The 
patients fail to understand the connection of things ; busi- 
ness and the affairs of society are not clearly and readily 


comprehended, leading to errors in formation of opinions 
and in the motives for action, that which we call impair- 
ment of judgment. Here we find the basis for many of 
the delusions. These are mostly of a persecutory char- 
acter ; the patients believe they are being neglected, little 
things are done to annoy them, and finally they are de- 
prived of property. Lack of insight into their increasing 
infirmity, necessitating the appointment of a conservator, 
leads to other ideas of persecution. Expansive delusions 
may also appear. Egotism becomes marked and self-inter- 
est with the gratification of personal whims precede every- 
thing. This may advance to genuine avarice, the feeling 
of greed overwhelming even filial affection. 

In emotional attitude there is a variation between elation 
and depression, depending in a great part upon the con- 
tent of the delusions ; but indifference and lack of sym- 
pathy are prominent characteristics. The patients fail to 
enter into the sorrows and joys of those about them, 
and feel no grief at the loss of dearest friends. They 
are also irritable, peevish, and discontented. The states 
of the emotional attitude are both superficial and transi- 
tory ; extreme and tearful sympathy or silly happiness 
may be aroused on the slightest pretext. 

In actions the most noticeable features are delirious 
restlessness at night and silly, childish behavior. Some 
of the patients display a certain stupidity, with a loss 
of energy and a tendency to sleep the greater part of 
the day. Others exhibit restlessness with some exalta- 
tion, and a feeling of confidence which leads them into 
foolish business schemes and outlandish adventures. Asso- 
ciated with this activity there is often present increased 
sexual feelings, causing the patients to enter into improper 
sexual relations and in extreme conditions to expose them- 


selves. Other patients wander about aimlessly, busy them- 
selves with trifles, make foolish plans, and indulge in 
excesses. They may grumble, curse, and abuse in the 
vilest terms. The restlessness at night consists of getting 
out of and dishevelling the bed, wandering about the 
house, and rummaging chests and closets without purpose. 
Patients are unable to care for themselves properly, and 
are dirty about their clothing. 

Senile Confusion. — The second form represents a deeper 
grade of deterioration, and as such often appears as the 
final stage in simple deterioration. Senile dementia, how- 
ever, may appear at first and run its full course as senile 
confusion. This form is characterized by great disturbance 
of apprehension, with clouding of consciousness and disori- 
entation. The patients mistake those about them for old 
acquaintances, have not the least conception of where they 
are, the season of the year, or the date. They undress at 
midday, thinking it night, and call the physician by their 
husbands' names. They say they are twenty-five years of 
age, have had twenty-five children, the oldest of which is 
twenty-five years, that they still have their menses, and 
are now pregnant. They are easily distracted and show 
a marked limitation of thought, with a constant reversion 
to the same senseless talk. Many changing delusions are 
expressed, both of depression and elation, and sometimes 
of a nihilistic nature. Hypochondriacal ideas are promi- 
nent ; by leaning against a radiator a hole has been 
burned through the flesh into the lungs, causing the heart 
to cease beating ; they cannot speak, eat, or sleep ; nothing 
has passed their bowels in weeks, and the liver has rotted 
away. They are to be poisoned or murdered. On the 
other hand, they imagine that they possess much prop- 
erty, hold an important position, or are in communication 


with God. Many of these ideas are embellished with 
numerous fabrications. Hallucinations of sight and hear- 
ing are frequently present. 

In emotional attitude the patients are sometimes appre- 
hensive and dejected, sometimes irritable, and at others 
elated and happy. In actions they display more or less 
restless activity, which is especially marked at night. They 
regularly tear and throw about their bedding, creep about 
the room, picking into the corners, destroying and smear- 
ing their clothing, or laugh, sing, and run about in a silly 
manner. The patients are very untidy, and incapable of 
caring for themselves. There is great insomnia, and very 
little nourishment is taken. 

Senile Delirium. — This form is characterized by a more 
acute onset and a short course with great disturbance of 
comprehension, incoherence of thought, and delirious ac- 
tions. It often appears as an episode in the course of 
senile deterioration. When occurring independently, it 
frequently follows an acute illness or some mental shock. 
Patients suffer from many hallucinations of sight and hear- 
ing. They hear voices, threats, singing, see the devil, or 
crowds of men pressing upon them with knives. They 
are anxious and restless, claiming that they are in the 
world below, surrounded by mighty powers, are bewitched 
and poisoned, the house is being flooded, and huge boul- 
ders rolled about the room. They are completely disori- 
ented. The speech is irrelevant, incoherent, and flighty, 
often containing incomplete and unintelligible words. 
Echolalia is rarely observed. There is great activity; 
they rattle doors and windows in fear, shout for help, 
refuse food, resist, tear up the bedding, and crawl about 
the floor. The occupation delirium is frequently encoun- 
tered here, when the patients act in pantomime, addressing 


imaginary audiences, tending cattle, or driving horses. 
Insomnia is extreme. 

The course of the delirium is short, and presents many 
remissions, with more or less complete return to clear 
consciousness. On the other hand, the delirium may 
reappear after short or long intervals, and run a fatal 
course, or it may pass over into a state of anxious unrest. 
This state of unrest may persist, or in time entirely dis- 
appear. In unfavorable cases the delirium becomes ex- 
treme, leading to collapse from loss of physical strength, 
and death by some intercurrent disease. 

Physical Symptoms. — In senile dementia there is in- 
somnia, anorexia, and general fine tremor, which is to 

Fig. 5. — Senile Handwriting 

be distinguished from the tremor of the paretic by the 
numerous irregularities in the individual movements, which 
difference is immediately discernible in the handwriting. 
The accompanying illustration of the handwriting of the 
senile demonstrates this characteristic, and when com- 
pared with the handwriting of the paretic readily shows 
the difference between the two. There is also general 
muscular deterioration, noticeable in the increasing mus- 
cular weakness and the wrinkled and faded countenance. 
Speech disturbances are frequent, both aphasic and para- 
phasic. The speech is, in contrast to that of paresis, 
rarely hesitating. Hyperalgesia, paresthesia, ringing of 
the ears, and muscse volitantes are frequently present. 


Vertigo is rarely absent. The tendon reflexes are in- 
creased, and sometimes only on one side. The skin 
reflexes are abolished and the pupillary reflexes sluggish. 

Associated with the changes due to diffuse lesions of 
the brain, there occur in very many cases apoplectiform 
attacks. These may be simply attacks of vertigo, but 
more often are conditions of prolonged somnolence or 
coma, accompanied by general paresis of the muscles. 
These attacks are to be distinguished from apoplexy by 
the absence of hemiplegia. It is a characteristic feature 
of these attacks that, during convalescence, the paresis in 
the limbs is associated with weakness of the sphincters. 
Genuine apoplectiform attacks with hemiplegia are also 
of frequent occurrence, while the epileptic attacks are 
encountered in rare cases. The radial and temporal ar- 
teries usually give evidence of sclerotic changes, and the 
pulse is slow and irregular. 

Course. — The course of the disease is a progressive one 
to absolute dementia and death, similar to dementia para- 
lytica. The duration is from three to five years. An 
acute course may last but a few months. 

Diagnosis. — The gradual transition from the symp- 
toms of pure senility to simple senile deterioration 
offers some difficulty in the diagnosis. This is of extreme 
importance from a legal standpoint, as these cases cause 
more litigation than any other. The presence of delu- 
sions and of excitement should leave no doubt as to the 
presence of a psychosis. Senile dementia may be differ- 
entiated from melancholia by the appearance of hypo- 
chondriacal, nihilistic, and other silly delusions, and the 
disproportion between the defect of apprehension and 
emotional disturbance. Dementia paralytica has already 
been differentiated under that disease. The senile delir- 


ium, except for the underlying basis of deterioration, 
does not differ from the delirium encountered in other 

Treatment. — Naturally the treatment is limited to 
attention to the physical needs, proper hygiene, and 
improvement of sleep by hypnotics. In cases where there 
is great anxiety, it can be relieved by use of morphin or 
opium. (See p. 265.) In conditions of delirium, pro- 
longed warm baths, artificial feeding by stomach or nasal 
tube, with the addition of alcohol, and in case these meas- 
ures fail, padded beds or rooms, are indicated. The mild 
cases are best cared for at home. 


Fuerstner, Archiv f. Psy. XX, 2. 

Noetzli, Ueber Dementia Senilis. Diss. Zuerich, 1895. 

Alzheimer, Monatschr. f. Psy. u. Neur. 1898, S. 101 ; Centralbl. f . 

Nervenheitke, 1899, 519. 
Campbell, Journal of Mental Science, 1894. 
Colella, lStude sur la Folie Senile. Annali de Neurologia, 1899, An. 

XVI, fasc. 6, S. 430-456. 


This term is applied to that mental disorder which 
recurs in definite forms at intervals throughout the life of 
the individual and in which a defective hereditary endow- 
ment seems to be the most prominent etiological factor. 

The greater number of cases usually called recoverable 
mania, simple mania, simple melancholia, periodical 
mania, periodical melancholia, and circular insanity 
belong to this group. These diseases, viewed according 
to the old conception, always presented difficulties because 
of the frequent occurrence of conflicting symptoms. In 
periodical melancholia, there appeared evidently maniacal 
symptoms, and the picture of circular insanity was fre- 
quently marred by the appearance of two successive ma- 
niacal or melancholic attacks. Any series of ten cases of 
periodical mania or periodical melancholia, in each of which 
there has been at least three attacks closely observed, dis- 
closes such varying features that one is forced to conclude 
that these manifestations, inharmonious with the old con- 
ceptions, are not accidental, but phases of one disease pro- 
cess. The constant recurrence of certain fundamental 
symptoms in all the attacks, the uniformity of their 
course and outcome, and the occasional intimate relation 
of different forms of the disease, where one form passes 
over either gradually or rapidly into another, has led to 
the conclusion that the individual attacks appear in one 
of three forms, the maniacal, the depressive, or the mixed. 

The maniacal forms are characterized by psychomotor 
excitement, flight of ideas with sound associations, great 



distractibility, pressure of activity, happy though un- 
stable emotional attitude, unstable delusions, some 
hallucinations, and comparatively little clouding of 

The depressive forms are characterized by psychomo- 
tor retardation, absence of spontaneous activity, dearth 
of ideas, dejected emotional attitude, prominent delu- 
sions and hallucinations, and usually clouding of con- 

The mixed forms present a combination of the symp- 
toms characteristic of each of these conditions. 

Such a conception of the disease, with characteristic 
fundamental symptoms, makes its recognition possible 
immediately at the onset, without having to wait for the 
occurrence of more than one attack. 

Etiology. — Manic-depressive insanity comprises from 
ten to fifteen per cent, of admissions to insane hospitals. 
The disease is more common in women than in men. Of 
the etiological factors, defective heredity is the most prom- 
inent, occurring in from seventy to eighty per cent, of 
cases, a larger percentage than in other mental diseases, 
excepting in imbecility and idiocy. Previous to the 
onset of the psychosis, many patients have displayed 
peculiarities, some having been abnormally bright, while 
others have been eccentric or overpious. Physical stig- 
mata may also be present. Individual attacks, except 
the first, almost always appear independently of external 
causes. Of external causes, besides gestation, alcoholic 
excesses are perhaps the most prominent; others are 
mental shock, deprivation, and acute diseases. In the 
greater number of cases, the first attack appears before 
twenty-five years of age, and in less than ten per cent, 
after the fortieth year, in both of which periods women 


predominate. The first and subsequent attacks often 
occur during pregnancy and puerperium; but it is a 
noticeable fact that these do not cease with the period of 

Pathology. — Thus far observation has failed to reveal 
any characteristic anatomical pathological changes. This 
fact, together with the recurrence of individual attacks, 
mostly independent of external causes, has led to the con- 
clusion that the disease depends upon a neuropathic basis, 
which in the vast majority of cases is hereditary. 

Meynert has offered a theory of the pathological basis 
of the disease in explanation of those cases which alternate 
from a maniacal to a depressive attack, or vice versa. He 
observed that in the maniacal states there was a full 
hard pulse, flushing of the face and extremities, from 
which it was inferred that there was also a hyperemia 
of the brain. In the depressive states the opposite was 
true, an unsteady weak pulse and vascular spasm of the 
extremities, and probably anemia of the brain. Upon 
these grounds Meynert advanced the theory that the 
disease was due to a vascular disturbance. The prolonged 
vascular spasm in the depressive states would naturally 
be followed, as the result of fatigue, by vascular relaxa- 
tion and cerebral hyperemia, with a clinical picture of 
mania. This theory is inadequate, because it does not 
establish a basis for the mixed states. A theory presented 
by Meyer, which explains the disease by a trophic vascular 
disturbance, is still more improbable. 

Symptomatology. — The apprehension and comprehension 
of external impressions show more or less disturbance in 
the maniacal forms, except in the lightest — hypomania. 
This disturbance is due largely to the great distractibility 
of the attention. The patients lose the ability to select 


and elaborate their impressions, because each striking 
sensory stimulus forces itself upon them so strongly that 
it absorbs their entire attention for a moment, while the 
next instant another stimulus takes its place. Their 
attention may be held for a moment by holding objects 
before them, but it is quickly distracted by something 
else. Under these circumstances, consequently, the en- 
vironment is never fully apprehended, and the picture 
remains disconnected and incomplete, although there is 
no serious disorder of the perceptive process. The central 
susceptibility to external impressions is, however, dimin- 
ished, as is seen in the remarkable insensibility to heat 
and cold, to hunger, and to pain. In the depressive 
forms apprehension is more manifestly and extensively 
disturbed ; especially is this true in stupor. Even in the 
lighter forms the patients are unable to elaborate and 
comprehend well their impressions. Distractibility of the 
attention may be noticed, and even apathetic patients 
may be compelled to follow striking impressions. 

The consciousness in the maniacal forms is not clouded 
except in the more severe maniacal conditions and in the 
delirious form, when the hazy impressions and confused 
ideas lead to disorientation. One should not interpret 
as disorientation the capricious and playful use of false 
names for the physicians, attendants, fellow-patients, and 
even surrounding objects, unless from other sources it is 
perfectly clear that they do not comprehend their environ- 
ment. In the depressive phases the disturbance of con- 
sciousness is more pronounced, particularly in stupor, 
when the patients for months may fancy they experience 
the most extraordinary and dreamlike adventures. 

Hallucinations are very rarely present except in the 
delirious form, and in the more marked stuporous condi- 


tions, but even here they are neither a prominent nor per- 
sistent feature. Delusions also play an unimportant part 
in the maniacal forms. When present they are unstable, 
and appear in the form of playful boasts and exaggera- 
tions. A few patients elaborate delusions of persecution, 
especially directed against the family, or of poisoning, 
which are held for some time. In great excitement many 
variable expansive ideas may be expressed. In the de- 
pressive phases, on the other hand, the delusions of perse- 
cution and of self-accusation, as well as hypochondriacal 
ideas, are usually present. These delusions rarely become 

There is usually some insight into the disease ; but while 
the patients appreciate that they have undergone a change, 
they attribute it to misfortune and abuse rather than to 
mental illness. 

The disturbance of thought is a prominent symptom. In 
the maniacal forms a definite line of thought cannot be 
followed out ; ideas pass abruptly from one subject to an- 
other, and the line of discourse is lost in a mass of detail. 
A short question may be answered correctly, but with the 
addition of a host of details and side remarks that have 
only a distant relation to the subject. It is impossible for 
the patients to relate any event coherently without fre- 
quent inquiries and suggestions on the part of the listener 
to draw him back from his digressions. There is a lack 
of voluntary guidance of the train of thought, hence there 
are quick leaps in the succession of ideas influenced by 
objects that happen to come into the field of vision, or by 
sounds caught up from the surroundings. On the whole, 
there is a multitude of ideas, but they are not well con- 
nected. Ideas seem to crowd each other, but in reality 
they do not. There is no controlling goal idea. The 


association of ideas follows along the tracks most fre- 
quently used, especially those that play an important part 
in daily expressions, such as bits of slang and common 
phrases. The resulting incoherence of thought gives rise 
to the so-called flight of ideas. Observation of external 
objects may seem to be very accurate and complete, but 
in reality it is superficial. A striking object attracts the 
attention, is apprehended, and starts a train of thought ; 
but before this has proceeded far something else obtrudes 
upon the sensorium, and another is started. In spite of 
appearances, genuine thought is retarded. Instead of an 
acceleration of the train of ideas, there is only flightiness 
and an instability. Ideas are rapid, but they do not 
crowd one another. There is an abundance of words, not 
of ideas. 

In the depressive and mixed forms there is retardation 
of thought. The process of thought is greatly impeded, 
and there is really a dearth of ideas, causing the patient 
to appear stupid. The reaction to questions is apt to 
be monosyllabic. Such patients have been regarded as 
demented, until closer observation has demonstrated that 
there is no real deterioration. 

The emotional attitude in the maniacal forms is more 
or less elated and happy. There is a feeling of well-being 
with a tendency to joke and to make facetious remarks. 
Expressions of the emotion are unrestrained. Irritability 
is prominent, giving rise at times to outbursts of anger 
from trivial causes, but even more characteristic are the 
rapid changes in the emotional attitude ; in the midst of 
joy patients become tearful, complaining of abuse and 
misfortune ; in spite of profound misery they may burst 
out into boisterous laughter. These varying states appear 
and disappear with the greatest rapidity. Depression of 


spirits may appear even for a few hours, indicating a 
close relationship between the maniacal and depressed 
phases. In this form depression is the predominating fea- 
ture, and there is despair, gloom, and often anxiety ; but 
even in their dejection one sometimes encounters moments 
when there are feeble attempts at laughter and even gayety. 
The mixed forms present stupor with silent mirth, or rest- 
less mischievousness with anxiety. 

The most prominent symptoms are found in the psy- 
chomotor sphere. The increased facility for the convey- 
ance of stimuli into action gives rise to pressure of 
activity. Every sort of impulse leads to an action, com- 
pletely inhibiting all normal volitional impulses, or even 
if a volitional action is begun, it is overwhelmed before 
half accomplished. Furthermore, almost imperceptible 
impulses excite the greatest variety of movements, which 
are executed with unusual energy. In the lightest forms 
this appears a characteristic restless activity and an 
excessive display of energy over trifles. If the disease 
is more severe, the actions become disconnected. New 
impulses intrude before any one object can be accom- 
plished. In the severest excitement the actions change as 
rapidly as the ideas, and are quite aimless. The actions, 
however, depend upon and bear a definite relation to the 
ideas and emotions. The intensity of the motor excite- 
ment depends largely upon external stimuli, the removal 
of which offers a substantial relief. Unrestrained activ- 
ity tends to increase the excitement. The ready release 
of the motor impulses perhaps accounts for the unusual 
absence of fatigue in these conditions, which may persist 
for weeks or even months without any signs of exhaustion. 

This psychomotor pressure of activity is prominent also 
in the field of speech. This is important in the produc- 


tion of the flight of ideas. The easily aroused motor speech 
dispositions have a stronger influence in directing the train 
of thought than the ideas arising from purely intellective 
processes. Instead of a logical sequence of ideas, we find 
that the motor coordinations determine their succession ; 
thus we encounter those associations common in the every- 
day life, set phrases, slang, and rhymes, and finally pre- 
dominance of pure sound associations, when we hear such 
productions as " Sam, jam, bang, slam, hell, shell, bells," 
etc. Silence is impossible. The patients prattle away 
and shout at the top of their voice, scream, declaim with 
many gestures and in a pompous manner, perhaps ending 
in unrestrained laughter, or they sing now softly, now 
slowly. The following is a sample of the maniacal 
production : — 

" I was looking at you, the sweet voice, that does not 
want sweet soap. You always work Harvard, for the 
hardware store. Here is the right hand, the hand that 
they shot off yesterday. The love of God don't win gray 
hairs. I don't care if I am nineteen, my father taught 
me to love. Neatness of feet don't win feet, but feet win 
the neatness of men. Run don't run west, but west runs 
east. I like west strawberries best. Rebels don't shoot 
devils at night. For three years I got over seven dollars 
a month and some old rags. Take your time and be not 
disobedient, be grateful and when judgment day comes. 
God's laws are all right, but Royal Baking Powder is com- 
pressed yeast. Women should never chew gum. Women 
should never smoke. Women should mind their own 
business. Fish-hooks are between the American flag, red, 
white, and blue, Fourth of July. You must pay for your 
own fiddler, Prudence. I am no tobacco chewer, I am no 
street walker, I am vaccinated, but McKinley does not 


win. My father is a Democrat. He had no work for 
three years." 

Such incoherence is not the outcome of an excessive 
repletion of ideas, but results from an inability to give 
direction to the train of ideas. A normal individual at 
times might give expression to a similar production if he 
could utter the sequence of ideas as they came into his 
mind. In the disease picture this ideomotor excitability 
regularly leads to the expression of every idea that pre- 
sents itself. 

The letter-writing of maniacal patients shows with 
equal clearness the same disturbance. Single phrases and 
sentences may be well started, but are soon resolved into 
a senseless enumeration of catch phrases, bits of slang, 
and rhyme. The script is coarse and bold, while under- 
lining, overwriting, and punctuation marks predominate. 

The psychomotor field, in the depressive forms, presents 
a retardation of activity, due to the slowness of convey- 
ance of sensory and ideational stimuli into impulses. In 
the mildest degree this retardation appears as a deficiency 
in the power of resolution. Actions may not only be per- 
formed slowly, but even after being started may fail of 
completion. The simplest movements, such as walking 
and talking, are performed very slowly and without 
energy. Unless extreme, the retardation may be over- 
come under extraordinary circumstances, such as impend- 
ing danger, when there may be display of considerable 
energy. In the severest forms the retardation leads to a 
complete abolition of all voluntary movements, leaving 
the patient in a condition of stupor, and even the move- 
ments of expression are dominated by this same condition. 

The above description of the symptomatology serves as 
a picture of the disease process as a whole. The disease 


picture as it appears in the different phases needs a 
more detailed description for its recognition. Further 
study may lead to a different conception of the three large 
groups, — the maniacal, depressive, and mixed, — but at 
present we must regard them as phases of one disease 
process. Each of these groups has still further been 
divided into smaller groups, according to the intensity of 
the symptoms : maniacal forms, comprising hypomania, 
mania, and delirious mania; depressive forms, simple re- 
tardation, retardation with hallucinations and delusions, 
and stuporous conditions ; mixed forms, maniacal stupor, 
stuporous mania. It is a question whether this subdi- 
vision is justified, since we find many cases in which the 
intensity of the symptoms varies, and a patient in one 
attack may pass through the whole cycle of changes in 
all three groups. 

Maniacal States 

This, the mildest maniacal form, has also been desig- 
nated mania mitis, or mitissima, and folie raisonnante. 

The onset is often gradual. After a short period of 
indisposition there appears an unusual activity. The 
patients are up at early morning, bustling about with 
unnecessary business, take long walks, and give much 
time to pleasure. They develop freaks of conduct : devote 
much time to family genealogy, attempt journalism, pur- 
chase property, begin to build, write many letters, and 
renew old friendships. The actual capacity for work, 
however, is much diminished. They lack perseverance, 
become negligent, and apply themselves only to that which 
is agreeable. They show a morbid tendency to attract 


attention ; they dress in a conspicuous manner, wear flow- 
ers, and use perfume. A sedate old merchant persisted in 
wearing a red tie, silk hat, colored hose, and tan boots. 

There is complete absence of insight into their condi- 
tion. The patients justify their actions against criticism 
in a most persistent way, and never fail for plausible ex- 
cuses. In the realm of ideation they show a moderate 
flight of ideas, and this is more especially noticed in 
letters. They shift abruptly from one subject to another, 
and are quite unable to bring a thought to a logical con- 
clusion. They are very talkative, the content of conversa- 
tion being centred about commonplace affairs, their expe- 
riences and difficulties. They revel in minute details, and 
often distort the facts with exaggerations and frequent 
misrepresentations. In the highest grades there is a strik- 
ing lack of coherence in the train of thought. The 
patients are unable to arrange logically a series of ideas 
without abrupt transitions from one subject to another. 
Upon effort they may be able for short periods to gain 
the mastery over their incoherent thoughts, as well as 
over their excessive activity. They may appear brighter 
and clearer minded than usual because of their ability to 
grasp remote resemblances, but in reality they cannot make 
use of any valid comparisons. 

The memory is slightly inaccurate only for recent 
events. Self-esteem is very prominent; they boast of 
their own deeds and show a proportionate lack of ap- 
preciation for those of others. They believe themselves 
misjudged or falsely confined, as they never were more 
healthy or capable of work. Usually, in their estimation, 
the relatives and friends, or those who have been instru- 
mental in their confinement, are the ones in need of 
hospital treatment. 


The emotional attitude is usually elated. Patients are 
happy, cheerful, and often exuberant. They derive great 
pleasure from their associations and undertakings. They 
take great delight in making facetious remarks and in 
taunting helpless patients. They are jovial and friendly. 
On the other hand, they may show great irritability. 
When thinking of their restraint they may become dis- 
contented and grumble, and when opposed may show 
violent fits of abusive anger. They are completely under 
the control of sudden impressions and emotions, which 
quickly acquire an irresistible power over them. 

Physical Symptoms. — The number of hours of sleep is 
cut short by late retiring and early rising, but their actual 
sleep is profound. The appetite is regularly improved, 
and the weight may increase. The skin appears healthy, 
and the movements are strong and elastic. 

The course of this form is usually uniform except where 
hypomania appears only as an episode in the other forms. 
The improvement is very gradual, and often accompanied 
by remissions. The duration is seldom less than several 
months, and sometimes over a year. This condition often 
follows pure mania. 


The onset of the purely maniacal condition is almost 
always sudden, following a short period of headache or 
malaise. A few days of simple depression may precede 
the onset. The patients rapidly develop great psychomotor 
restlessness, with a pronounced flight of ideas, clouding of 
consciousness and disorientation, great impulsiveness, transi- 
tory expansive delusions, and occasional hallucinations. 

The activity of mania is much greater than that of 
hypomania. Patients cannot sit or lie still ; they run back 


and forth, dance about, turn handsprings, sing, shout, and 
prattle incessantly, make all sorts of gestures, tear off cloth- 
ing, pull down the hair, clap the hands, smear the person 
and room with grotesque designs, ornament themselves in 
the most fantastic manner with clothing which has been 
torn into strips. Everything that they can lay their 
hands upon, from watch to shoes, is taken to pieces. Bits 
of straw and pieces of stone, glass, and food are hoarded 
to plaster up a crevice in the wall or to pack a keyhole. 
In the absence of tobacco all sorts of material are used, 
— leaves, and bits of thread, and even dried feces. They 
are especially apt to cram the nostrils and ears with 
foreign material, and to carry bits of glass, nails, stones, 
and nutshells in the mouth. A patient secreted a four- 
inch nail and an extracted tooth in his mouth for months. 

They are quarrelsome and domineering, or mischievous 
and playful. Because of great irritability, the most trivial 
affairs may lead to extreme violence and abuse. Female 
patients are more apt to show this tendency than male. 
Sexual excitement is manifest in shameless masturbations, 
exposure, and demands for intercourse ; by indecent atti- 
tudes and insinuating remarks. 

Consciousness is more or less clouded. This is seen in 
partial or complete disorientation. Patients know the 
time and where they are, but they perceive only in a 
superficial way the events of the environment. Those 
about them are apt to be mistaken for old acquaintances. 
Sometimes they designate them as historical personages, as 
congressmen, public officials, or well-known millionaires. 
Apprehension and comprehension are greatly interfered 
with by the extraordinary distractibility ; sounds from the 
surroundings are caught up and woven into their speech ; 
an object held by the physician, or parts of his clothing, 


attract the attention and quickly lead the thought in 
another direction, which is just as abruptly left before 
the thought is half expressed, aiding in the production of 
a genuine flight of ideas. They understand what is said 
to them, and are able to give short answers to questions 
which are correct and pertinent. In this way facts con- 
cerning their past lives and occupation can be obtained by 

Hallucinations are apt to play an unimportant part and 
are transitory and changeable. Sometimes faces are seen 
on the wall, shining objects appear on the ceiling, and 
flash-lights are seen as signals in the sky. Noises are 
heard, floors creak, locomotives whistle, bells ring, and 
poisonous vapors are set free in their rooms at night. 
Sometimes they feel electric shocks. 

Delusions, mostly expansive, seldom depressive, are 
prominent. They present manifold changes, are transi- 
tory, and embellished by numerous fabrications. The 
patients claim that they are royal personages or generals, 
that they have supernatural strength, can produce planets, 
and are related to God. Many of these ideas are recog- 
nized by the patients as pure fabrications, are expressed 
with a laugh, and forgotten the next moment. A few 
single delusions may be adhered to for a long time. Very 
often a patient shows some insight into his disordered 
condition, admitting that he is crazy and cannot control 

In emotional attitude the patients are mostly happy and 
elated. Irritability, on the other hand, is very marked. 
Trifling affairs, such as interference or contradictions, may 
lead to outbursts of passion with profane abuse, assaults, 
or destruction of the clothing or other objects. The rapid 
changes of the emotions are still more characteristic. In 


the midst of joy they begin to lament and shed tears at 
the thought of home, or because of the abuse which they 
claim to have received at the hands of their nurses. Fre- 
quently they show a very sudden change to a condition of 
passion and rage. 

Physical Symptoms. — The sleep is more or less dis- 
turbed and nutrition suffers in spite of increased appetite. 
The weight always falls. 

Course. — The height of the disease is usually reached in 
the course of a week or two, and in some cases within a 
few days. The intensity of the disease is fairly uniform, 
with only slight fluctuations. Occasionally there may 
appear a sorrowful and depressed emotional condition, 
with disappearance of the motor activity, or even a transi- 
tory stupor, indicating a transitory depressive phase. The 
improvement is very gradual ; although for some time after 
there is comparative clearness, the patients are apt, under 
strain, to show a flight of ideas, and some increased activity. 
Even after apparent complete recovery, trying conditions, 
reverses and misfortunes, and more often intoxication can 
cause a recurrence of the symptoms. The duration extends 
over many months, and sometimes two or three years ; in 
rare instances as long as five to seven years. 

Delirious Mania 

This, the most extreme of the maniacal states, is char- 
acterized by considerable clouding of consciousness, intense 
psychomotor activity, great incoherence of speech, a high 
grade flight of ideas, numerous hallucinations, and dream- 
like delusions. 

The onset is sudden, following a few days of indisposi- 
tion, uneasiness, and insomnia. The patients immediately 
develop the greatest restlessness, incessantly running about, 


shouting and singing, disrobing, destroying everything 
within reach, becoming recklessly violent, and smearing 
themselves. At one moment they are praying, at the 
next cursing with the vilest language or singing an 
obscene song; at one time they are insulting in speech 
and action, and a minute later are profuse in apologies and 
distastefully affectionate. They chatter away, sc*ream and 
stamp their feet, pound the window or door, race at the 
greatest speed along the corridor, mount the table and 
declaim in a loud voice with profuse and exaggerated 

Their speech is incoherent, abounding in sound associa- 
tions, rhymes, and numerous repetitions of single syllables 
and phrases, in which one can always detect many 
fragmentary references to objects in their environment. 
The attention usually cannot be attracted except momen- 
tarily, when a fragment of the desired response can be 
detected in the incoherent speech. Striking objects, such 
as a penny dropped on the floor, will divert the attention 
and the train of thought for a moment. 

From the first the consciousness is greatly clouded, and 
disorientation is almost complete. The patients are thor- 
oughly confused as to time, place, and persons ; they mis- 
take their environment, and even their friends. Dreamlike 
hallucinations and delusions appear. The hallucinations 
are numerous and are present in all of the sensory fields ; 
they see beautiful sights, strange faces, and scenes of tor- 
ture ; hear distant music, ringing bells, cannonading, and 
the roar of wild animals. Their food has a peculiar odor 
and taste, and small objects crawl on the skin. They see 
fire and hear the crackling timbers. 

The manifold changing delusions are both expansive 
and depressive; they are the "chosen ones"; have been 


elected President ; have wonderful power, can create and 
destroy nations, possess millions; they have lost all 
friends ; are to be murdered ; must enter hell ; have been 
taken to an immense height and are now to be cast into 
the sea. Some are on trial for murder, or have been trans- 
ferred to Mars. 

In emotional attitude there are rapid changes between 
extreme happiness and profound distress, ecstatic joy and 
timidity, exuberance and apathy. Irritability is very 

Physical Symptoms. — The state of nutrition suffers pro- 
foundly because of the small amount of food taken and the 
great expenditure of energy. Occasionally there is a gen- 
eral muscular tremor. Sleep is greatly disturbed, and at 
the height of the disease is entirely lacking ; the pulse is 
accelerated and the reflexes are exaggerated. Evidences of 
congestion of the head are sometimes noticed ; the con- 
junctivae are injected, the vessels of the head and face 
distended, and there is occasional profuse perspiration. 

Course. — The height of the attack is quickly reached, 
usually within a few days or weeks, and the symptoms 
begin to abate at the third or fourth week. Short inter- 
vals of composure, varying from a few minutes to a few 
hours, during which the consciousness is clouded, suddenly 
appear and disappear. The improvement is rapid. The 
patients usually retain for some time residuals of their 
delusions and peculiarities of conduct, and are inclined 
to be irritable and distrustful. Finally in the course of a 
few weeks these signs entirely disappear. There is rarely 
any memory for the events of the acute stage of the psy- 
chosis. A fatal termination is very rare and usually occurs 
through some intercurrent disease, exhaustion, injuries, or 


Depressive States 

The depressive states are divided into three groups, — 
simple retardation, retardation with hallucinations and 
delusions, and the stuporous conditions. 

Simple Retardation 

This is the mildest form of depression ; it is characterized 
by simple retardation without either hallucinations or promi- 
nent delusions. The onset is generally gradual, except in 
a few cases, which follow acute illness or mental shock. 
Mental processes become retarded ; there appears gradually 
a sort of mental sluggishness ; thought becomes difficult ; 
the patients find difficulty in coming to a decision and in 
expressing themselves. It is hard for them to follow the 
thought in reading or ordinary conversation. They fail 
to find the usual interest in their surroundings. 

The process of association of ideas is remarkably re- 
tarded ; the patients do not talk because they have noth- 
ing to say; there is a dearth of ideas and a poverty of 
thought. Familiar facts are no longer at their command. 
It is hard to remember the most commonplace things. 
They appear dull and sluggish, and explain that they 
really feel tired and exhausted. They sit about as if be- 
numbed, with folded hands and bowed head, exhibiting no 
initiative and rarely uttering a word voluntarily. What 
is said is uttered in low, inexpressive tones. Customary 
actions, such as walking, dressing, and eating, are per- 
formed very slowly, as if under constraint. When started 
for a walk they halt at the doorway or at the first turning- 
point, undecided which way to go. Although mentally 
retarded, consciousness is unclouded and the environment 
is correctly apprehended. 


In the emotional attitude there is a uniform depression. 
The patient sees only the dark side of life. The past and 
the future are alike full of unhappiness and misfortune. 
Life has lost its charm ; they are unsuited to their envi- 
ronment ; are a failure in their profession ; have lost reli- 
gious faith, and seem to live from day to day in gloomy 
submission to their fate. They are disgusted with every- 
thing ; do not care to live longer. They fear business 
reverses and begin to economize, even denying themselves 
and their families the necessaries of life. Patients fre- 
quently express a desire to end their existence, but they 
seldom make a serious attempt at suicide. Insight is fre- 
quently present, the patients appreciating keenly that they 
are mentally ill. 

The retardation may at some time during the course of 
the psychosis develop into a condition of stupor. The pa- 
tients then lie in bed perfectly dumb, unable to comprehend 
their surroundings or to understand questions, and without 
expression of emotion, except in rare instances, when a 
look of anxiety or perplexity comes over the countenance. 
If able to answer questions, the response is exceedingly 
slow. When a question not having been readily answered 
is followed, even at quite an interval, by another, the ques- 
tions may be answered in the order propounded, indicating 
probably that the disturbance is psychomotor rather than 
intellectual. The patients are unable to care for them- 
selves. They sit helplessly before their meals, allowing 
themselves to be fed by spoon, and holding firmly whatever 
may be pressed into their hands. This stuporous condition 
disappears rapidly, leaving no memory of the events. 

This form of depression runs a rather uniform course 
with few variations. The improvement is gradual. The 
duration varies from a few months to over a year. 


Retardation with Delusions and Hallucinations 

The second group is characterized by hallucinations and 
varied delusions of persecution and self-accusation, in addi- 
tion to psychomotor retardation and difficulty of thought. 

The onset of this form is usually subacute or acute, fol- 
lowing a period of indisposition, and occasionally even a 
short period of exhilaration and buoyancy of spirits ; a few 
cases appear after an acute illness or mental shock. 

The patients are profoundly despondent, indulging in all 
sorts of self -accusations. They feel that they have been 
great sinners, have neglected their duties, and made many 
enemies ; have never done anything right, and their whole 
life has been one long series of mistakes. They accuse 
themselves of bringing misfortune on others, or of causing 
some great calamity. They claim that they have no feel- 
ing, no sympathy for others, and no more tears. They 
feel that they are being watched, fear arrest and impris- 
onment, and may even claim that the scaffold for their 
execution is already erected. People hold them in deri- 
sion, laugh and jeer at them. Others are incriminated by 
their misdeeds, and are suffering imprisonment. They 
have lost everything, and will be driven into the street 
with their families, to wander about in utter misery. They 
have sold themselves to the devil, and will be taken to hell. 

Hypochondriacal delusions are prominent ; their health 
is ruined, they are in the clutches of some malignant dis- 
ease, different organs are wasting away ; cloudy urine sig- 
nifies profound disease of the kidneys, and the presence of 
a cough is sufficient evidence of the last stage of consump- 
tion. Female patients may complain of being pregnant, 
or of uterine tumors. Many, both men and women, com- 
plain of sexual abuse. Their various delusions may become 


absurd and fantastic. One very common delusion is that 
everything about them is altered : their home is not their 
own, the room is changed, their relatives are gone, and 
never will return ; they are not in the right place, have 
been removed to another world; they themselves are 
changed, are but a shadow, a skeleton, without life, which 
can neither live nor die. The heart has ceased to beat, the 
stomach and intestines are entirely gone, and even if their 
heads were cut off they would still continue to live. 

Hallucinations are occasionally associated with this con- 
dition; groans and moans are heard, disagreeable odors 
permeate the room, terrible apparitions appear at night, 
and fearful scenes are depicted. 

The consciousness is for the most part unclouded ; the 
patients are oriented, and comprehend correctly what tran- 
spires in their environment. They understand questions, 
and answer coherently; but the content of thought and 
speech shows a constant tendency to revert to their depres- 
sive delusions. They are self-centred, and think only of 
their own misfortune. Thought is difficult, as is seen 
when they attempt to write letters or to think over a 
problem. They tire easily during visits. 

Insight into the condition is very often present, yet 
while admitting recovery from previous similar attacks, 
they declare that their present condition is so much worse 
that they can never recover. The emotional attitude is 
uniformly depressed. The patients are dejected, gloomy, 
and perplexed. Sometimes they lament for hours in mo- 
notonous tones. Although conscious of the surroundings, 
they appear utterly indifferent to them. 

In conduct the psychomotor retardation is evident in 
their slow and hesitating replies to questions, and their 
sluggish and languid movements. Further, there is almost 


no independent action. There is often considerable anx- 
ious restlessness, when the patients pace up and down the 
room, sway the body, or rock uneasily in a chair, picking 
at the clothing or rubbing the head. Occasionally the 
patients attempt suicide. 

There are a few cases which present coherent delusions 
of persecution accompanied by many hallucinations with 
clear consciousness, which remind one very much of alco- 
holic delusional insanity, save for the psychomotor retarda- 
tion. The hallucinations play a rather important part, 
and persist for a long time. 

Physical Symptoms. — The patients complain of numb- 
ness in the head, of a feeling as if there were weights upon 
the chest, and of palpitation of the heart. The appetite 
is poor, the tongue coated, and the bowels constipated. 
There is usually a strong aversion to food. The sleep is 
broken and disturbed by anxious dreams. The eyes are 
lustreless, the skin is sallow and without its accustomed 

The course of this form shows variations with partial 
remissions and very gradual improvement. The duration 
extends from six to eighteen months. 

Stuporous Conditions 

The third group of depressive cases is characterized by 
numerous incoherent and dreamlike delusions and hallu- 
cinations, with a pronounced clouding of consciousness. 
This form rarely appears alone, but usually forms an epi- 
sode in the course of the other forms. In the latter case 
it develops gradually. Otherwise the onset is sudden. 

The patients are so absorbed in their delirium that there 
is scarcely any response to external stimuli. For them 
everything seems changed in the most fantastic manner ; 


the whole world is being consumed by fire or congealed 
into ice. They themselves are removed from everybody, 
have been taken up into a cloud and carried off to the far- 
thest point of the universe, and left there alone. They 
are to be shoved off into space where they will keep fall- 
ing forever, or they are crowded into a narrow grave from 
which they can never escape. The walls of the room are 
closing in upon them, and passing troops have arrived to 
attend their execution. Crowds jeer at them; they are 
made to wear a crown of thorns or are turned loose to 
run naked in the street. Everything about them has a 
most mysterious aspect ; they are in the midst of histori- 
cal personages, and are made to do penance for the whole 
world. They have been transformed in a most horrible 
manner : have two heads, the body of a serpent, and the 
feet of an elephant. While in this dreamy state they are 
considerably retarded, lying in bed thoroughly indifferent ; 
only the anxious expression, the resistance to passive 
movements and peculiar postures, betraying their anxiety 
and fear. Occasionally a few words or sentences are 
uttered slowly and in low tones. They do not eat, and 
are entirely unable to care for themselves. 

The improvement is gradual, with persistence of hallu- 
cinations and some delusions even after the consciousness 
has become clear. Besides the physical symptoms noted 
in the other forms, there is a profound disturbance of nu- 
trition, with considerable loss of weight, great insomnia, 
foul odor of the breath, extreme constipation, or occasion- 
ally diarrhoea. The height of the disturbance is reached 
in a few weeks and runs a short course of from four to 
eight months. 


Mixed States 

The third phase of manic-depressive cases presents a 
combination of the fundamental symptoms appearing in 
the other two. An indication of the close relationship 
between the maniacal and the depressive phases of the 
disease has already been demonstrated in the transitory 
periods of depression in the maniacal, and of exhilaration 
in the depressive states. A depressed patient may retire 
at night dejected and retarded, and awake happy, exhila- 
rated, and active. For a few hours, or even a whole day, 
he may exhibit typical maniacal symptoms, when suddenly 
the cloud again settles down upon him and he becomes 
depressed and retarded as before. Occasionally a hypoma- 
niacal patient attempts suicide as a result of depression. 

Simultaneous appearance of maniacal and depressive 
symptoms characterizes the mixed states. In conditions of 
deep depression there may persist a strain of happiness in 
the emotional attitude and a facilitated release of voluntary 
impulses. A depressed patient may smile at absurd remarks 
in his presence or say something witty ; or the active, boast- 
ful, maniacal patient may be ill-humored and discontented, 
expressing anxiety and fear. In mixed states there are 
two groups of cases corresponding to the predominance of 
the symptoms of one of the states over those of the other, 
called respectively maniacal stupor and stuporous mania. 

Maniacal stupor is characterized by a maniacal state 
with undoubted evidences of retardation. These patients, 
in spite of pressure of activity, display a poverty of thought 
and a slowness of apprehension and comprehension. The 
attention is poor, questions are not understood unless re- 
peated with emphasis, and even then absurd replies may 
be made. They are not especially talkative, yet they do 


not remain silent for very long at a time. Their speech, 
is incoherent and often very monotonous. Conversation 
may even drag until the patient gets warmed up. Their 
manner and conduct may lead to the suspicion that the 
patients are deteriorated until at some time or other they 
suddenly appear alert, giving pertinent and even quick- 
witted replies. 

In emotional attitude they are cheerful and serene, laugh- 
ing both with and without sufficient provocation. The 
pressure of activity is not striking, being limited, perhaps, 
to self-adornment, grimacing, and mischievous annoyance 
of others. A superficial examination often fails to reveal 
any undue activity; but closer observation discloses their 
incapacity for any systematic occupation in spite of orderly 
behavior. They show an inclination toward pranks and 
tricks. They hoard up scraps, plunder rooms, and pick 
their clothing to pieces. There is an evident lack of pre- 
meditation in all of their actions. Occasionally they may 
break things impulsively, pound furniture, overthrow fellow- 
patients, or smash windows. 

In stuporous mania there is a predominance of stupor 
over the maniacal symptoms. These patients are inactive, 
sluggish, lying abed most of the time or sitting unoccu- 
pied, seldom speaking voluntarily, and only occasion- 
ally answering questions, and then always in low tones. 
Some entertain a few changing depressive delusions. Con- 
sciousness is clear, and they seem to be oriented. In the 
midst of this stuporous condition they suddenly develop 
great activity, rush about, disrobe, tear their clothing and 
destroy furniture, sing and talk loudly and freely, often 
make bright and striking remarks, and then after a few 
hours as quickly return to the previous stuporous state. 
One patient would sit on a settee with downcast coun- 


tenance, apparently oblivious of the surroundings, never 
responding to questions or to the calls of nature : suddenly 
she would leap up from her seat and waltz down the hall 
in step to a tune which she would hum, but in the course 
of a few moments would again return to the seat and 
assume her previous attitude. 

It is not usual for such a state to form the picture of the 
entire psychosis ; it occasionally appears as an episode in the 
course of a maniacal attack, but more often forms a part of 
the transition state between a maniacal and a depressive con- 
dition. Other less definitely mixed states are encountered 
in the transitional period between individual attacks. 

Course. — The course of manic-depressive insanity is 
marked by recurrence of attacks separated by lucid inter- 
vals. With but very few exceptions, following the first, 
others recur throughout the life of the individual, appear- 
ing with greater frequency between the ages of eighteen 
to thirty and forty to fifty. In a small percentage of 
cases, four to five per cent., the attacks from the first pass 
directly from one into another, sometimes with such regu- 
larity that the name "alternating insanity" has been 
applied to them, or where short intervals have intervened, 
" circular insanity.' ' If but one or two attacks occur dur- 
ing the life of an individual, the separate attacks are in no 
way essentially different from those recurring frequently. 
Usually the first forms the type for the majority of the 
succeeding attacks, that is, the first being maniacal, the 
majority will be maniacal ; it seldom happens that all are 
of the same type : at some time or other a depressive attack 
is sure to appear. On the other hand, one patient during 
life may suffer from all possible forms, from hypomania to 
profound stupor. 

Where the first attack occurs before thirty years of age, 


and especially in women, it is most often depressive. This 
first depressive attack is often followed by one of a mania- 
cal character. Two consecutive depressive attacks at the 
beginning are rare. A first maniacal attack is almost 
always followed by a lucid interval, seldom by a depressive 
attack. The mixed forms usually do not appear until 
after two or three attacks of either the maniacal or depres- 
sive form. The single attacks vary in length from a few 
weeks to two to five years, the usual duration being from 
six to twelve months. As the attacks recur, their duration 

The lucid intervals vary considerably in length, from a 
few days or weeks to many years, and stand in no definite 
relation to the duration of the attacks. They are apt, 
however, to be longer at the beginning and shorter as the* 
attacks recur, until finally they may disappear altogether, 
the attacks passing directly from one into another. Dur- 
ing the intervals the patients are perfectly lucid except in 
a few cases where the attacks are long, frequent, and 
severe. The patients are able to reenter the family, to 
employ themselves profitably, or to conduct business. 
Even the few who do not thoroughly recover are able to 
leave the hospital, but are apt to show some restraint, 
lack of independence, a tendency to be morose, an unusual 
susceptibility to fatigue, an instability with a diminished 
capacity for work, or they may be irritable and self-con- 
scious. During the interval some of the patients fail to 
show genuine insight. They realize that they have been 
" excited and nervous," but attribute it to family trouble 
and confinement in a hospital. The lucidity of a long 
interval may be interrupted by short periods of moderate 
exhilaration, flightiness, and unusual activity, or on the 
other hand the patients may be unnaturally apprehensive, 


suspicious, and despondent. Where the attacks pass from 
one into another, the transition is gradual, reaching over a 
period of several days, during which time it is possible to 
detect states similar to those encountered in the mixed 

The transition from a maniacal to a depressive phase, or 
vice versa, is usually gradual, though it may occur during 
a night. In this transition the stages of alteration are 
usually quite perceptible. At first the countenance of the 
depressed patient becomes more open and the eyes appear 
brighter and the skin firmer and more elastic. The patient 
is more affable, shows more interest in the surroundings, 
and expresses a desire for freedom. The activity, at 
first increasing slowly, now becomes prominent : he is 
busy all the time, is happy, never felt better in his life, 
and everything pleases. From this time the maniacal 
state becomes quite evident. The maniacal patient at first 
gradually loses weight, the pressure of activity abates, he 
is calmer and more in earnest, his many schemes recede to 
the background and then entirely disappear. Soon his 
movements become languid, he himself is seclusive, talks 
less, only occasionally mentioning his ill feelings and mis- 
fortunes. His countenance loses its freshness, and at last 
we have a typical depressive state. 

Prognosis. — The prognosis of the disease is unfavor- 
able in view of the certainty of the recurrence of attacks 
throughout the life of the individual. It is favorable for 
recovery from the individual attacks, except in a small 
percentage, four to five per cent, of cases, which from the 
onset pass directly from one attack into another. While, 
with this exception, it is sure that there will be other 
attacks and recoveries, the frequency of their recurrence 
and the duration of the lucid intervals is entirely uncer- 


tain. At present we have no means of judging just what 
the future course will be. In general it may be said, how- 
ever, that it is safe to predict frequent recurrence of attacks 
with short intervals where the psychosis manifests itself 
early and without external cause. 

If the onset is previous to the period of involution, one 
should expect a recurrence during the climaterium. There 
is a tendency to mental deterioration only in a few cases 
where the attacks are long, frequent, and severe ; but even 
these patients, in the intervals, are conscious, well oriented, 
and retain a very good memory. They are indifferent and 
irritable, and very susceptible to alcohol, and may be 
deficient in judgment. These defects increase with the 
recurrence of attacks ; but even after many years the dete- 
rioration is very moderate and can be distinguished from that 
of other psychoses by the persistence of some of the fun- 
damental symptoms characteristic of the disease, such 
as distractibility, pressure of activity, retardation, etc. 
Finally, there are a few cases, especially those with a 
greater predominance of attacks of one type, which, after 
many years, continue permanently maniacal or depressed. 

Diagnosis. — There is usually little difficulty in recogniz- 
ing the psychosis, where there has been a previous attack ; 
yet the occurrence of more than one attack is by no means 
pathognomonic of manic-depressive insanity, as it may 
occur in dementia praecox, especially in the catatonic form, 
in melancholia, and in senile delirium. A knowledge of 
the fundamental symptoms of the disease makes it possible 
to diagnosticate it immediately in the first attack. The 
diagnosis depends in the maniacal state upon the great dis- 
tractibility, little clouding of consciousness, flight of ideas 
with tendency to sound associations, pressure of activity, 
happy but unstable emotional attitude, paucity of delusions 


and hallucinations, and absence of evidences of deteriora- 
tion; in the depressive states it depends upon psycho- 
motor retardation, absence of spontaneous activity, dearth 
of ideas, dejected emotional attitude, moderate clouding 
of consciousness, and absence of evidences of mental 

The differentiation of the disease from the exhaustion 
psychoses and from the excited stages of the catatonic and 
hebephrenic forms of dementia prcecox will be found fully 
detailed in the differential diagnosis of those diseases. 

The maniacal form is differentiated from hysterical ex- 
citement by the presence of the flight of ideas, pressure 
of activity, and intractable behavior. Hysterical excite- 
ment subsides quickly and completely after but very 
short duration. The delirious form may be confounded 
with the dreamy state of the epileptic. In the epileptic 
the content of thought is uniformly dreamlike and con- 
trolled by hallucinations and delusions, and in emotional 
attitude patients are irritable, uneasy, and ecstatic ; while 
the maniac shows fear and rapid changes of emotion with 
a predominance of exhilaration. 

It is more difficult to distinguish simple retardation from 
the initial period of depression in dementia prcecox. In 
the manic-depressive patient the psychomotor retardation, 
with slowness of movement, low tone of voice, difficulty 
of thought with sparsity of ideas, slowness of application 
of attention, and slight clouding of consciousness, stand 
out in contrast to the absence of retardation, freedom of 
movements, and thought without consistent interference 
with the flow of ideas and to the clearness of consciousness in 
dementia praecox. Rapid appearance of senseless delusions 
and numerous hallucinations without clouding of conscious- 
ness speak for dementia praecox. 


The differentiation of the depressive states from demen- 
tia paralytica and melancholia have been discussed under 
these psychoses. 

Acquired neurasthenia is sufficiently differentiated from 
the depressed forms under that disease. 

The mixed states most frequently lead to error in their 
recognition. They have sometimes even been mistaken 
for the excitement of imbecility. They are to be differen- 
tiated from the catatonic condition by the absence of 
negativism. If in the mixed states the patients struggle, 
the cause for it lies in the irritable, fretful disposition, 
which almost always leads to abuse and violence. In 
stuporous mania the patients pay more attention to their 
environment, and are biassed in their actions by circum- 
stances, in contradistinction to the sluggish or wilful indif- 
ference of the catatonic. They furthermore display a 
poverty of thought and not a stereotyped and senseless 
speech production. The movements in catatonic patients 
are apt to be planless, instinctive, and with a uniform press- 
ure of movement, while in stuporous mania they are play- 
ful and adapted to the environment. 

Treatment. — Individuals who have suffered from an 
attack of this disease should be compelled to lead a quiet 
life, free from irritating influences. They are very sus- 
ceptible to alcohol, and should avoid its use most scrupu- 
lously. They should be advised against marriage, and, 
if married, against further child-begetting. In patients 
who suffer from regular and frequent recurring attacks, 
graduated doses of trional or sulphonal may reduce the 
intensity of the excitement, or ward off altogether an 
approaching attack. Berkley recommends for the same 
purpose atropia given in full doses. 

In the separate attacks of the maniacal forms it is essen- 


tial to remove at once all forms of external irritation, and, 
except in very mild cases, removal to a hospital is neces- 
sary, and even the milder forms run a more moderate course 
under the influence of quiet and well-regulated hospital 
surroundings than outside. Unrestrained activity tends 
to increase the excitement, and there is, therefore, an 
indication to limit as much as possible the pressure of 
activity. One of the best means of accomplishing this is 
confinement in bed, especially those cases which are anemic 
and debilitated. In severe excitement, prolonged warm 
baths give excellent results. It, however, may be nec- 
essary, in accustoming the patient to the baths, to tempo- 
rarily give a preliminary dose of sulphonal fifteen grains, 
or hyoscin hydrobromate -^-q to -^ grains. This accom- 
plished, the warm bath properly applied will often relieve the 
greatest excitement, and frequently renders medicinal treat- 
ment unnecessary. When unavailable, the use of hyoscin 
hydrobromate hypodermically or by mouth is an excellent 
measure for subduing intense activity. After the excite- 
ment subsides, the prolonged bath, combined with occa- 
sional freedom from all restraint, is of value. In very 
extreme excitement with impending collapse, the adminis- 
tration of alcohol, in the form of whiskey or brandy, or 
camphor is necessary, and in the case of coexisting 
cardiac weakness, digitalis or caffein should be added. 
Prolonged and extreme insomnia may necessitate the use 
of hypnotics, of which sulphonal and trional are most ser- 
viceable. Another important indication is the manage- 
ment of the patients, in which it is absolutely essential 
that the greatest amount of tact and patience be used; 
gentle friendliness at suitable moments very often renders 
what appears to be a most dangerous patient quite trac- 
table. This requires that the nurse exercise complete self- 


control, be free from all prejudices, avoid all use of 
discipline, and above all be frank and truthful. The 
nutrition of the patient demands special attention. An 
abundance of nutritious and easily digested food should 
be offered the patients at frequent intervals. It often 
requires considerable patience to accomplish this. In 
severe cases the patients should be weighed daily in order 
to ascertain if the body weight is falling off, and where 
necessary artificial feeding by stomach or nasal tube can be 
employed. It is very often a difficult matter to deter- 
mine when the patients are well enough to be discharged 
from treatment, because of their great importunity and 
impatience to be set free while some symptoms still remain. 
One of the greatest dangers arising from an early discharge 
is the tendency to alcoholic indulgence. A safe guide for 
deciding this question may be found in the weight, which 
should return to normal. 

In the depressed states, accompanied by agitation, opium 
or morphin is often indicated to induce quiet (see p. 265). 
Evening baths with cold effusions and careful massage 
may be used with great benefit. A carefully prescribed 
routine, with good nutritious diet, ample rest in bed, and 
outdoor exercise, is always indicated. Special attention 
should be paid to digestion. All sources of emotional dis- 
turbance should be avoided, such as the visits of relatives, 
long conversations, letters, etc. Attempts to comfort the 
patient in the height of the disease seem to be useless. 
In the lighter cases hypnotic suggestion has been used to 
great advantage in relieving the insomnia, despondency, 
and disagreeable somatic sensations. The greatest care 
must be exercised to prevent suicidal attempts, which are 
often to be most guarded against at times when the 
patients, though still convalescing, believe themselves 


recovered, and also in the transition period between two 


Kirn, Die periodischen Psychosen, 1878. 

Mendel, Die Manie, Eine Monographie, 1881. 

Emmerich, Schmidt's Jahrbuecher, CXC, 2. 

Pick, Circulaeres Irresein; Eulenburg's Realencyclopaedie, 2. Auflage. 

Hoche, Ueber die leichteren Formen des periodischen Irreseines, 1897. 

Hecker, Zeitschrift fur praktische Aerzte, 1898, 1. 

Weygandt, Ueber die Misch Zustaende des manisch-depressiven Irre- 
seines, Munich, 1899. 

Hoch, Maniac-depressive Insanity, Reference Handbook of Medicine, 
toI. V, 1902. 


Paranoia is a chronic progressive psychosis, occurring 
mostly in early adult life characterized by the gradual 
development of a stable progressive system of delusions, 
without marked mental deterioration, clouding of conscious- 
ness, or involvement of the coherence of thought. 

Since the adoption of this name by Mendel in 1881 its 
application has shown wide variation. Many psychiatrists 
consider only the character of the development of the 
psychosis and its early symptoms, and pay little or no 
attention to the course of the disease as a whole or its out- 
come. Others have applied the term to any psychosis in 
which the predominant symptoms were primary delusions 
and hallucinations. These views together with the con- 
sideration of the disease process, either as a purely affective 
mental disturbance, or as involving the intellectual sphere 
alone, account for the use of such terms as periodical para- 
noia and acute paranoia with recovery. A mental disease 
should not be characterized alone by the presence of hal- 
lucinations or delusions, primary disturbance of the intel- 
lect, or of the emotions without regard to the course and 
the outcome. The many unsuccessful attempts to classify 
the forms of paranoia according to the psychological symp- 
tomatology has usually led to the conclusion that the vari- 
ous transition forms into other psychoses predominate in 
the clinical picture. This naturally interferes greatly with 
the integrity of any disease picture. It is the careful 
study of the clinical symptomatology in conjunction with 



the etiological factors, the course and the outcome, which 
has led to the recognition of the disease picture described 

Etiology. — The disease is not common, constituting only 
two to four per cent, of the cases admitted to insane hospi- 
tals. Men are more often afflicted than women. The dis- 
ease begins between the ages of twenty-five to forty. It 
develops on a defective constitutional basis, either con- 
genital or acquired, defective heredity existing in a very 
large percentage of the cases. Peculiar traits and eccentric- 
ities may be recognized early in life, the patients being 
moody, dreamy, or seclusive. Some show perverted sexual 
instincts, or a marked aptitude for study or mental activ- 
ity in special limited fields. Some have been abnormally 
bright; others have always been flighty, entering into 
many projects which they were unable to pursue success- 
fully; many show stigmata of degeneration. Exciting 
causes occasionally form the starting-point of the psychosis, 
such as an acute illness, excessive mental stress, shock, 
business reverses, deprivation, and disappointment. 

Pathological Anatomy. — There is as yet no demonstra- 
ble pathological anatomical basis peculiar to paranoia. 1 

Symptomatology. — The development of the psychosis 
is very gradual, extending sometimes over years, and is 
usually so insidious that the disease is in existence long 
before it is recognized. During this period it may have 
been noticed that the patient had changed in disposition, 
having become somewhat irritable, grumbling, suspicious, 
and easily discontented, and that he had made indefinite 
physical complaints, especially of malaise and insomnia. 

1 Berkley, however, mentions that the most striking pathological sign 
encountered by him is the abnormal topography of the cerebral cortex, 
the intersection of sulci and malposition of convolutions. 


The first symptom to be noticed is that the daily mental 
or manual labor becomes distasteful, and little affairs at 
home or in the shop cause displeasure and arouse suspicion. 
The wife seems less attentive, the children less loving, 
shopmates less friendly, and the overseer more stern. The 
accidental absence of the morning greeting, or imaginary 
slight on the part of a close friend, sets the patient to think- 
ing that it cannot all be accidental. He becomes distrust- 
ful, is constantly seeking other evidences of unfriendliness, 
and careful watching soon satisfies him that he is neglected, 
both at home and at work. He begins to make complaints, 
accuses his friends of slights, and members of his fraternity 
of plots. He leaves his employment, holds aloof from his 
companions and friends, and often becomes rude and dis- 
courteous. Some patients are able to ignore for a time the 
apparent indifference of friends, but others become much 
disturbed and suspect a malicious purpose. They are mor- 
bidly sensitive, considering that such trifles as harmless 
jokes, smiles, or accidental nods of the head have special 
reference to themselves. Items in the paper indicate some 
intrigue, bill posters contain hints, some daily passer 
always lights his cigar or coughs when near them ; men 
similarly dressed always meet them near the same corner, 
or are shadowing their footsteps. Any doubts as to an evi- 
dent purpose in all this are sooner or later dispelled by 
remarks accidentally overheard. In this way false inter- 
pretations gradually assume greater prominence, and the 
resultant persecutory delusions are constantly increased and 
aggravated. Those who conscientiously approach and 
question friends or supposed intriguers are further alarmed 
and justified by the indifference displayed and the little 
satisfaction obtained ; some ignore them, others answer eva- 
sively. Trivial matters which formerly passed unheeded 


are now falsely and absurdly interpreted and enter into the 
structure of their delusions. A spot on the coat, a cal- 
loused finger, a decayed tooth, or headache are all regarded 
as positive proof of treachery and an effort to get them out 
of the way by a slow process of poisoning. The appear- 
ance of natural baldness is readily explained by the appli- 
cation of electricity during sleep. 

Sooner or later, in connection with these delusions of 
persecution, which are firmly held and well moulded by a 
coherent train of reasoning, there may also appear expansive 
delusions. These may be coincident with the persecutory 
ideas at the onset of the disease, but more frequently are 
the outcome of the delusions of persecution. The increas- 
ing attention which the patients attract, and the persistent 
persecution lead them to cast about for the reason. While 
some find this in property which they really possess, others 
believe that it lies in their personal charms, while still others 
conclude that they have been born for a special mission, or 
are of noble descent. A thrifty Irish woman, who had 
accumulated considerable property by dint of hardest labor, 
finds a sufficient cause for her persecution in attempts of 
her enemies to secure her hard-earned accumulations. A 
factory employee already approaching the limits of the cli- 
materic, finds the reasons for her persecution in her attrac- 
tive appearance, and the desire of eminent men to seduce her. 
Where the expansive delusions are more directly evolved 
from the delusions of persecution, the patient asks himself 
why he is so molested and tormented, why so many, not 
only individuals, but nations, seem directly interested in 
him, and why he is constantly accompanied by a secret 
patrol. Gradually it dawns upon him that he is a kid- 
napped son of a millionaire, or of a crowned head ; that he 
is of Napoleonic descent and lawful heir to the throne, 


while his extensive landed properties are unlawfully used 
by the government. This explanation first appears in the 
tendency to find evidences of persecution in many or all 
the events of their environment, and becomes prominent 
when the patients discover its purpose. Then all these 
supposed facts assume a place in the chain of evidence 
which confirms their conclusions. 

These delusions may only assume the form of an exag- 
gerated feeling of self-importance. The patient considers 
himself especially renowned in his profession, — a fine 
lawyer, an excellent teacher, an interesting talker, an ideal 
gentleman, a social favorite, or an individual worthy of 
great political distinction. Finally a change of personality 
may result, and the patient announces himself as titled, or 
a direct descendant of Christ. The patients become aware 
of this in various ways, one once receiving a salutation 
from the President, another recognizing a striking similar- 
ity between himself and the equestrian statue of a famous 
general. Others are assured of their high station by the 
deference paid them by every one : people bow to them, 
their names are in the paper, the orchestra begins to play 
as they enter the theatre, the prima donna directs her song 
at them, and the birds chirp when they are near. The 
appearance of the sun from under a cloud, casting its rays 
upon them, indicates that they are under the special guid- 
ance of God. 

All delusions, both persecutory and expansive, are held 
with great persistency, and built out into a coherent system, 
which is an essential characteristic of the disease. 

In the systematization of the delusions another promi- 
nent feature is the frequent appearance of retrospective 
falsification of memory. While this symptom is mostly 
characteristic of paranoia, it may also be present in the 


paranoid forms of dementia praecox, and in melancholia. 
Here the patients, in reviewing their past life, find evi- 
dences of persecution, or detect occurrences which at the 
time should have indicated their superiority. The loss of 
a situation many years ago, derisive remarks by fellow- 
workmen, or an injury, now become clear evidences of their 
persecution by enemies. One patient recalled that when 
thirteen years of age a priest took from her a book, claim- 
ing that it was unfit for her to read. This incident she 
now regards as the beginning of years of persecution by the 
priesthood, who would seduce her and then hold her up as 
an example before the world. Another patient led his 
class in marching, and later was chosen captain of the 
boys' brigade : these incidents at that time should have 
made him aware of the fact that he was to have been a 
famous general. Another remembered overhearing his 
parents whisper in an adjacent room, becoming mute at 
his entrance, and later a disguised woman, who was really 
his mother, visiting at the house, all of which pointed to a 
noble birth and his displacement by a younger brother. 
Many similar incidents scattered throughout life are pointed 
out as striking evidences which aid in fortifying their sys- 
tem of delusions. 

An erotic element often appears in the delusions, which 
in some cases has been pronounced enough to lead to the 
recognition of an erotic paranoia. Likewise, the religious 
coloring is sometimes strong enough to establish a religious 

In the erotic cases the patient usually believes himself the 
object of admiration by some lady who is attracted to him, 
and solicits his attention. She makes him aware of this 
by daily appearing at her window as he passes, or by cast- 
ing sly glances as she drives by. Other evidence is gath- 


ered by anonymous love poems in daily papers. Numerous 
fantastic methods of communicating his love to her are 
devised, to which she responds by wearing certain articles 
of clothing, or arranging her hair differently. Their 
mutual admiration is publicly regarded as an open secret. 
He hears it indirectly referred to everywhere, and friends 
would have him infer, from casual remarks, that they are 
well pleased. Sometimes this fanciful, romantic, and even 
platonic love is maintained for years without action ; at 
others, the patient makes an effort to approach his sup- 
posed fiancee. Her rebuffs may at first be regarded as 
necessary for the accomplishment of her desires. Later 
she may appear to him in the guise of one of his com- 

Hallucinations are always present at some time, but do 
not play a very important part in the psychosis, and rarely 
persist through the whole course of the disease. Hallucina- 
tions of hearing are apt to be the most prominent. At first 
very indefinite noises annoy them. Later they hear their 
names mentioned, or derisive laughter from a crowd ; 
nicknames are called out, some one curses below the win- 
dow, and bits of conversation from adjoining rooms excite 
them. The remarks are more often of a depreciatory 
nature. Hallucinations of sight are rare, but those of gen- 
eral sensibility are quite frequent, — the hair is plucked at 
night, the skin irritated by poisonous powder, the flesh 
pierced by bullets, or the countenance transformed by the 
nightly application of an iron mask. 

There is never genuine insight into the disease. • The 
patient, on the other hand, may complain of all sorts of 
physical ailments, such as nervousness, indigestion, pains 
in the head and back, for which he seeks medical attend- 
ance ; but he cannot be made to realize the fallacy of his 


delusional ideas. The memory is well retained, and judg- 
ment, except as biassed by the delusions, is unimpaired. 

The emotional attitude of the patients stands in direct 
relation to the character of the delusions. They are irri- 
tated by their persecutors, are shy and excitable, and at 
first usually despondent; some, however, tolerate the per- 
secution and regard it as essential to their spiritual wel- 
fare. All sooner or later become arrogant, proud, and 

In conduct the patients appear quite normal for a con- 
siderable time. Some of them, long before the real nature 
of their disease becomes evident, attract attention by their 
eccentricities, peculiarities in dress, oddities in manner, 
excessive religious zeal, or an attitude of self-importance. 
Later they become seclusive, move about in their employ- 
ment from city to city, leave one shop to enter another, 
where they soon detect the presence of their former perse- 
cutors, and are again compelled to leave. In this way an 
iron moulder travelled from San Francisco to Boston in 
order to avoid the persecutions of his trade-union. A 
change affords only temporary relief to the anxiety, as 
suspicious circumstances are soon noticed which leave no 
doubt that news about them have been passed on from 
their last situation until finally their existence becomes 
known the world over. They become unstable in their 
behavior and mode of living, are unable to conduct a suc- 
cessful business, and fail to support their families. In 
reaction to the delusions they attempt to call public atten- 
tion to their persecution by writing newspaper articles and 
issuing pamphlets. Very often they apply to the police 
for protection. Frequently they assume the offensive, and 
take the matter of vengeance into their own hands. Not 
infrequently the first striking evidence of the disease is a 


murderous assault upon some one. The paranoiac is for 
this reason the most dangerous of all insane. One patient 
assaulted the mayor of the city for keeping him from his 
fiancee; another shot at a passing milkman, whom he 
believed had been poisoning his cattle and bewitching his 
sister; another drew a pistol upon a man with whom he 
was having an altercation over business matters, in the 
belief that he was the secret agent of the French govern- 
ment sent to kill him. 

In accordance with expansive ideas, the patient may 
address the President as his father, or demand access to a 
millionairess whose parents are keeping them apart. If 
.confined in an institution, they may for a time ingeniously 
conceal their delusions until they find evidences of con- 
tinued persecution in their new surroundings, when the 
fellow-patients appear to them only as accomplices placed 
there to aid in their discomfort. Sometimes their confine- 
ment is regarded as an effort of their persecutors to make 
them insane. Some patients submit gracefully to their 
detention, considering it but another cross to bear before 
their final rescue and the proclamation that they are right- 
ful rulers. A few patients even consider that they are 
being treated with the utmost consideration and the great- 
est attention, provided with the best quarters, and granted 
every possible privilege by those who recognize the great 
injustice done them. 

The course of the disease is protracted. The onset is 
always gradual, and usually the disease has been in prog- 
ress for some time, even a few years, before recognition. 
When once established, the course is slowly progressive 
with a gradual evolution of delusions which are constantly 
being further systematized and made to encompass new 
environment. Several psychiatrists claim that the course 


of the disease presents definite periods according to the 
stages of evolution of the delusions. At first there is 
the prolonged period of insidious onset, by Regis called 
the period of subjective analysis, followed by the perse- 
cutory period with the development of delusions of per- 
secution with hallucinations, and finally the ambitious 
period accompanied by a change of personality. The 
patients usually are quite orderly, present an unclouded 
consciousness, and for many years are capable of consider- 
able labor, both mental and manual. After a duration of 
many years there appears a moderate degree of mental 
weakness. Patients become unable to apply themselves, 
take less notice of their environment, and less care of 
themselves. In some cases the disease may seem to be 
at a standstill for years, while in others partial remissions 
occur when the patients for a time are able to rejoin their 
families, but are rarely in a condition to resume their ac- 
customed occupations. 

The diagnosis depends upon the slow onset, the charac- 
teristic, coherent, and systematized delusions of persecu- 
tion with retrospective falsifications of memory, often 
associated with a change of personality, unclouded con- 
sciousness, coherent thought, and absence of mental dete- 
rioration for many years. 

The paranoid forms of dementia prwcox have already 
been differentiated from paranoia under the former 

A few cases of dementia paralytica and melancholia may 
simulate paranoia. Dementia paralytica is to be distin- 
guished by its rapid development, the early appearance of 
emotional weakness, and physical signs. The conduct of 
a paranoiac is entirely dependent upon the content of the 
delusions ; he cannot be reasoned with, is persistent in the 


prosecution of his ideas, and is rarely submissive to con- 
finement ; while the paretic opposes his retention weakly 
or intermittently and with some stubbornness. 

The melancholiac presents a more rapid onset (three to 
nine months), a marked disturbance of the emotional atti- 
tude, fear, self-accusations, occasional clouding of con- 
sciousness, an absence of system in the formation of 
delusions, and evidences of mental deterioration within 
the course of two years. 

The prognosis of the disease is very poor, as no case of 
genuine paranoia ever recovers. 

The treatment of the disease is naturally limited to the 
removal of irritating influences and to confinement in an 
institution where systematic routine with out-of-door life 
and ample exercise may ameliorate or ward off the condi- 
tion of mental weakness. 

There are a few cases of paranoia which have been 
designated by Hitzig as querulent insanity (Querulanten- 
wahn) * which deserve a brief description here. The 
psychosis is of gradual onset, and usually arises as the 
result of some legal injustice, — a defeat in court, an 
unjust award of damages, loss of property, or an unfair 
adjustment of claims, in which the patient has been the 
sufferer. He refuses to settle, carries the case from one 
court to another, and finally develops an insatiable desire 
to fight to the bitter end. He reaches a point where he 
is unable to view the standpoint of any one else with any 
sense of justice, and his personal belief and desire com- 
pletely obscure his better judgment. The statutes appear 
inadequate, and even the fundamental principles of the 
law fail of comprehension. He sets aside all business in 

1 Hitzig, Ueber den Querulantenwahn, 1895, Koppen, Archiv f. Psy., 
XXVIII, 221. 


order to carry on the struggle, solicits sympathizers, and 
denounces those who do not side with him. Hearsay and 
bits of knowledge gathered at random are cited as evi- 
dence in his behalf, and money is squandered in the pur- 
suit of justice to the most extreme limits. He cannot 
abide by the ultimate decision after all the usual means 
of justice have been exhausted. Failing to appreciate the 
needlessness of further struggle, he writes to magistrates, 
legislators, consuls, ambassadors, and finally to the Presi- 
dent or foreign rulers. Answers to these letters only 
create greater embitterment. His letters are long and 
carefully written, usually upon a particular kind of paper, 
and sometimes written with colored ink. 

The patient is irritable and often becomes greatly ex- 
cited in conversation, although at the same time priding 
himself upon his ability to exercise self-control. 

Consciousness remains unclouded. Memory is well pre- 
served, in fact it is often surprising to see with what 
accuracy he is able to quote from law books, to repeat 
parts of speeches, and to enumerate various dates. Thought 
continues coherent, but there is a great tendency to monoto- 
nous repetitions of the delusions. One seldom misses them 
in even a short conversation. 

There is no insight into the condition. On the other 
hand, the patient is often encouraged in his. belief by the 
fact that there are always many men, and not a few 
physicians, who will testify to his sanity. 

The few cases of querulency are apt, after a prolonged 
course, to present greater deterioration than other varieties 
of paranoia; the content of speech becomes more and 
more limited and somewhat incoherent, the irritability 
increases, the patient becomes peevish, indifferent, and 
sometimes even stupid. 



Snell, Allgem. Zeitschr. f. Psy., XXII, S. 368. 

Griesinger, Archiv f. Psy., I, S. 148. 

Sander, ibid., S. 387. 

Westphal, Allgem. Zeitschr. f. Psy., XXXIV, S. 252. 

Mercklin, Studien ueber priuiaere Verrueckheit, 1879. 

Amadei e. Tonnini, Archivio italiano per le malattie nervose, 1884, 

Werner, Die Paranoia, 1891. 
Schuele, Allgem. Zeitschr. f. Psy., L, 1 u. 2. 
Cramer, ibid., LI, 2. 
Sandberg, ibid,, LII, 6. 


The general neuroses comprise those diseased conditions 
which are accompanied by functional nervous disturbances. 
They are characterized in common by a morbid constitu- 
tional basis, and by the presence of peculiar transitory 
disturbances, involving sometimes the physical and some- 
times the psychical field. These latter disturbances, how- 
ever, must be regarded as exacerbations of a permanent 
diseased state. They simulate in this respect the attacks 
of manic-depressive insanity, but in the intervals a general 
change of the whole personality is more prominent in the 
general neuroses than in manic-depressive insanity. The 
group includes epileptic and hysterical insanities, and 
traumatic neuroses. 


Epileptic insanity is a complex accompanying epilepsy, 
characterized by a varying degree of mental deterioration, 
evidenced by impairment of intellect, and to a less extent 
of memory; emotional irritability, impulsiveness, moral 
anergy, and incapacity ; for valuable production. It also 
includes certain periodical disturbances, transitory ill-humor 
(Verstimmung), and dreamy states (Daemmerzustaende), 
which accompany epilepsy. 

Epileptic deterioration may appear at any period after 
the onset of epilepsy, and thus far no direct relation be- 
tween the number and severity of the convulsions and 
the degree of deterioration has been established. A patient 
with numerous (one or more daily) and very severe seiz- 



ures may present only moderate deterioration, with in- 
frequent and brief periods of excitement ; while another, 
who averages perhaps only five or six seizures yearly, may 
suffer from prolonged and repeated attacks of stupor, and 
show considerable deterioration. A few cases may present 
many or all the characteristic clinical symptoms of epileptic 
insanity without having any convulsions. 

Etiology. — Defective heredity is the most frequent cause 
of epilepsy, appearing in eighty-seven per cent, of cases 
where a complete family history was obtained, while in 
over twenty-five per cent, epilepsy had existed in the 
parents. Fere notes among progenitors and relatives of 
epileptics the extreme frequency of headaches, migraine, 
infantile convulsions, mental disturbances, and deterioration. 
Wildermuth considers that alcoholism exerts almost as 
powerful influence as mental disorders in the causation 
of epilepsy in children. Neumann states that in twenty- 
three and seven-tenths per cent, of cases one or both 
parents had been addicted to the use of alcohol. This 
abuse of alcohol is by far the most important external 
cause of epilepsy, as evidenced not only by the frequency 
with which it appears in chronic alcoholism, but by the 
great intolerance to its use displayed by epileptics, and 
the consequent increased intensity of the mental symptoms. 
Even when taken in small quantities, alcohol often leads 
to a characteristic intoxication, with profound disturbance 
of consciousness, faulty memory, and especially angry 

We may mention as evidences of congenital defect 
various physical stigmata, as malformation or asymmetry 
of skull, microcephaly, hydrocephalus, or " the epileptic 
physiognomy," which is characterized by a broad forehead, 
broad and flattened nose, prognathism, thick lips, and 


staring eyes with wide pupils. In thirty-four per cent, of 
cases, convulsions appear in infancy, while their devel- 
opment in childhood and later results from a series of 
insults in the form of acute diseases, mental shocks, fright, 
lesions of nerves, carious teeth, foreign bodies in the ear, 
or even sexual intercourse. The great variety of these 
causes indicates that they are not actual causes, but rather 
excitants of the convulsions. 

Head injuries are frequently assigned as the cause of 
epilepsy, and in a certain number of cases a direct relation 
between them can be traced. Wildermuth gives the fre- 
quency as three and eight-tenths per cent., and Heeres as 
four and two-tenths per cent. The numerous scars often 
found on the head are more frequently the results than the 
causes of the malady. 

Epilepsy often appears for the first time during the 
period of development, the impulse often being given by 
puberty or menstruation. On the other hand, it may 
appear later, particularly after infectious diseases, during 
the period of involution, or in senility, possibly in connec- 
tion with vascular changes (epilepsia tarda or senilis). In 
fourteen hundred and fifty cases Gowers found the follow- 
ing results : the onset of epilepsy occurred in twenty-eight 
and nine-tenths per cent, under ten years ; in forty-five and 
nine-tenths per cent, from ten to twenty years ; in fifteen 
per cent, from twenty to thirty years ; in nine per cent, 
from thirty to sixty years ; and in only thirty-four hun- 
dredths per cent, after the age of sixty. 

Pathology. — As all epileptics are not insane, it is evi- 
dent that the pathology of epileptic insanity must be 
based upon that of the seizures plus heredity, constitutional 
defect, and other factors whose nature and influence are as 
yet not thoroughly known. There is a wide variation in 


views as to the nature of epilepsy. Wildermuth asserts 
that thirteen and three-tenths per cent, of his cases were 
due to polioencephalitis, and five and eight-tenths per cent, 
to other gross lesions, as porencephaly, encephalic scars, 
neoplasms, malformations, multiple tubercles, etc. In the 
remaining eighty and nine-tenths per cent, of cases — called 
" genuine " or idiopathic epilepsy — various anatomical 
changes are found in the brain, which probably bear some 
relation to the clinical symptoms. The most important of 
these changes are an increase of the neuroglia tissue, espe- 
cially in the superficial layers of the cortex, and sometimes 
in isolated foci (Chaslin, Bleuler), and sclerosis of the cornu 
ammonis (Bratz, Nissl, Worcester). In senile epilepsy the 
senile vascular changes, as well as cellular degeneration, are 
usually pronounced. While the exact significance of these 
changes is unknown, the assumption may fairly be made 
that epileptic deterioration depends upon a general and 
profound disease of the cortex. 

The periodicity of the seizures may possibly be explained 
by the apparent tendency in the nervous system to a 
periodical reaction to any continued irritation. If the 
researches of Krainsky, Cabitto, and Agostini can be sub- 
stantiated, it would seem probable that genuine epilepsy is 
due to a toxic condition arising from faulty metabolism, 
and that the immediate cause of the convulsions is the 
accumulation of deleterious substances in the blood. This 
theory receives further weight from the fact that the con- 
vulsions are frequently accompanied by symptoms which 
point to intoxication : as drowsiness, headache, nausea, etc., 
and also from the fact that epileptiform attacks occur in 
many conditions of chronic intoxication, especially from 
alcohol, lead, and in uremia. But epilepsy, due to lesions 
in the brain, cannot be explained on the toxic basis. 


If we should base the known anatomical cerebral changes 
upon a chronic intoxication, there still remain to be ex- 
plained the periodicity of the attacks, the storing up of a 
toxin in the body, and also the hereditary relationship of 
epilepsy to other mental and nervous diseases. Indeed, 
these latter facts seem to indicate that the ultimate and 
characteristic cause of the symptom-complex, epilepsy, is to 
be found in morbid conditions of the nervous tissue. 

Symptomatology. — While a few epileptics may produce 
permanent and even distinguished mental work, in more 
than one-half the cases intellectual activity is impaired, 
though proportionally to a less degree than the emotions 
or volitions. In the majority of cases the degree of dete- 
rioration once established remains without marked prog- 
ress for years or even life, although in a few instances a 
condition resembling complete dementia may be attained, 
where patients practically lead a vegetative existence. 

In all cases of epileptic insanity there is a more or less 
pronounced mental, moral, and emotional weakness. Ori- 
entation is usually normal, and consciousness is clear except 
in the dreamy states. Apprehension is fairly keen for the 
daily routine, but attention is somewhat impaired or easily 

Hallucinations are exceedingly infrequent except in the 
dreamy states, especially anxious and conscious deliria. 
When found in the intervals, they are generally of a reli- 
gious character and are not prominent. Illusions are quite 
frequent for a short period before and after attacks of 
grand mal. Delusions are not common except in the 
dreamy states, where they are accompanied by or depend- 
ent on auditory and visual hallucinations, and are almost 
invariably of an ecstatic or terrifying character. 

There is generally a marked narrowness of the mental 


horizon, with limited ideation and imperfect association of 
ideas. In conversation or writing there is a strong ten- 
dency to detail and circumstantiality. New experiences 
are not readily assimilated or thoroughly elaborated, and 
patients keep in the beaten paths. Their vocabulary may 
consist largely of set phrases, platitudes, passages from the 
Bible, proverbs, etc. Their narratives are obscured by a 
multitude of data and irrelevant or unessential accessories, 
which greatly impede the progress toward, and develop- 
ment of, the essential points. The connection is not lost, 
however, and the aim is ultimately obtained by circuitous 

The narrowness of thought due to the lack of new 
experience and a faulty memory naturally leads to a 
greater prominence of the self. This is specially notice- 
able in the conversation of epileptics, in which they indulge 
in praise of self and family, and pay much attention to 
personal matters. The religious content of thought is 
another striking symptom, many patients spending a large 
part of their time in reading the Bible, prayer or hymn 
books, or engaging in prayer. Many attend strictly to 
religious duties, and a few, especially Protestants, exhort 
their fellow-patients. 

Memory is always impaired, sometimes to a great 
extent. While prominent events, by dint of frequent 
repetitions, may be recalled, the recollection of the general 
course of life, whether recent or remote, is more or less 
hazy. In distinction from the memory defects found in 
other deterioration psychoses, patients are able to express 
clearly and coherently their remaining narrow circles of 

Judgment is invariably impaired in proportion to the 
amount of mental deterioration. The true relation of 


ideas may be obscured or even lost, and often the most 
senseless and fantastic schemes are devised. Patients 
never fully recognize the incongruity between their 
grandiose plans and their limited ability. A man with 
marked mental and physical defects gravely proposed to 
study theology ; and another, who could hardly name the 
simplest flowers, desired to become a florist. As a rule, 
however, epileptics have some insight into their condition, 
realizing that they have convulsions, and cannot remember 
as well or think as easily as formerly. A few deny that 
they ever have epileptic seizures. 

Emotionally, the majority of patients show great vari- 
ations, even though intellect may be fairly well preserved. 
The finer feelings are generally blunted, and ordinarily 
there exists a rather uniform state of emotional indiffer- 
ence. There is, however, an increased irritability mani- 
fested by frequent outbreaks of emotional excitement, as 
well as sudden alternations from elation to depression, and 
the reverse. Some patients complain of an "internal 
anguish,' ' or fear. Many show an extraordinary hope of 
recovery from their " fits." An interesting feature of the 
emotional sphere is the fairly constant recurrence at regu- 
lar intervals of religious exaltation, morbid and baseless 
fears of illness or death, stereotyped lamentations, or irri- 
tability. One patient twice a year spends about two 
weeks reading the Bible and exhorting his fellow-patients, 
and for a part of this period is so excited and noisy that 
seclusion is necessary. Another just as regularly, although 
in robust health, imagines he is going to die, and with 
many tears implores the doctor to send for his brother and 
the priest. Many are very curious and meddlesome, and 
often get into trouble through their propensity to interfere 
with others. Epileptics often show increased irritability, 


either just before or after a seizure, and at these times 
more especially are threatening, quarrelsome, violent, and 
dangerous. 1 

Morbid and sudden impulses are frequent and charac- 
teristic symptoms of epileptic insanity. These are largely 
due to irritability or lack of self-control. Patients will 
attack any one who disturbs them, and often in a blind 
rage suddenly inflict severe and dangerous injuries, even on 
innocent and inoffensive bystanders, without any prov- 
ocation. These impulses are by no means confined 
to the pre- or post-paroxysmal stages, as many suppose, 
but may arise at long intervals between the seizures. The 
wild state of blind rage, where patients run amock, striking 
and assaulting indiscriminately every cne in their range, — 
the characteristic epileptic furor, — is a nerve storm which 
may justly be considered as an " equivalent." These 
sudden impulses to violence and even homicide render 
epileptics especially dangerous. Suicidal impulses are very 
infrequent, and their accomplishment still more so. 

The conduct, apart from the morbid impulses above 
described, is usually good. Epileptics as a rule are neat, 
orderly, and observe the ordinary rules of propriety unless 
deterioration is very profound. They often show kindness 
to others, and when a fellow-patient has a seizure will run 
to his aid, loosen his neck band, place a pillow beneath his 
head, and assist in carrying him to his bed. 

Some patients display marked sexual excitement, and 
some are inveterate masturbators. Epileptics show a 
diminished capacity for work, especially where the higher 
grades of mental and physical training are requisite. 
They may engage with fair success in simple routine 

1 On the other hand, there are a few patients who for years, or perhaps 
never, display any mood but one of placid amiability and gentle consideration. 


occupations, where little or no initiative is required; but 
unless carefully directed and watched, are apt to slight 
their work, or leave it unfinished. Their characteristic 
instability usually precludes permanent employment. Their 
physiognomy is quite typical, and epileptic deterioration 
can often be diagnosed by the experienced observer from 
the peculiar facies and speech. 

Physical Symptoms. — The most important physical 
symptoms in epileptic insanity are the seizures, which 
may assume the type of grand or petit mal. In the 
former there may be an aura, followed by a cry, a fall, 
and tonic followed by clonic convulsions, usually localized 
at first, but rapidly extending over the entire body. Dur- 
ing the convulsions, which may last from two to ten 
minutes, consciousness is totally abolished, but returns 
gradually within a period of a few minutes up to several 
hours. In status epilepticus there may be from twenty to 
over one hundred attacks of grand mal, without conscious- 
ness in the intervals. In petit mal there is a very brief 
loss of consciousness (usually only one or two seconds), 
either without any convulsive movements or with very 
slight ones, which often elude observation. The reflexes 
are abolished during the convulsions, and in some cases 
are not restored for one or more hours. 1 

1 In 1088 observations on male epileptics, made by the writer, the follow- 
ing results were obtained. The normal plantar reflex (flexion of toes, etc.) 
was present in both feet immediately after clonus had ceased, in forty-five, 
and one hour later in two hundred twenty-six cases; the Babin ski phe- 
nomenon (extension of toes with dorsiflexion of ankle) occurred in one 
hundred three cases directly after the seizure, and in one hundred twelve 
cases one hour later. An extensor response was found in right or left foot 
in ninety-nine and fifty-three cases respectively, and a flexor response in 
right or left foot in ninety-nine and two hundred eleven cases respectively ; 
while a mixed response, that is, extension in one foot and flexion in the 
other, occurred in eighty-two cases directly after a seizure and in one hun- 


The speech of epileptics is often altered and very charac- 
teristic. It is abrupt, with intervals after each phrase, 
often drawling, jerky, or strongly accented. During 
excitement it may be so rapid as to be indistinguishable, 
were it not for the fact that a few phrases are repeated 
over and over again. Organic and functional diseases of 
the heart are quite frequent, and the pulse rate is often 
increased. Epileptics rarely complain of headache, and 
often show an insensibility to pain amounting to anal- 
gesia, while their frequent wounds usually heal rapidly. 

On an epileptic basis we can recognize the following 
clinical divisions or forms : A, transitory periodical ill- 
humor (Verstimmung) ; and B, dreamy states, in which 
should be included pre- and post-epileptic insanity, psychic 
epilepsy, anxious delirium, conscious delirium, some cases 
of somnambulism, and possibly dipsomania. 

A. Transitory Periodical Ill-humor. — In this form 
the separate attacks bear an extraordinary resemblance to 
each other. The same complaints, the same delusions, 
and the same impulses recur. The phraseology of the 
patients is definite, the behavior characteristic, and the 
expression similar. These attacks vary in intensity, and 
often come on in the morning. Sometimes the intervals 
are so regular that the time of recurrence can be foretold 
with tolerable accuracy. Patients usually awake peevish, 
irritable, fault-finding, threatening, and quarrelsome; 
often commit sudden and unprovoked assaults on the 
nearest person ; break glass or destroy bedding and furni- 

dred forty-seven cases one hour later. The plantar reflex was abolished in 
six hundred sixty cases immediately after the convulsions, and in three hun- 
dred thirty-nine cases one hour later. The knee-jerks were active in three 
hundred ninety-six cases, moderate in one hundred thirty-seven, and absent 
in five hundred thirty-nine cases. 


ture, and use profane or obscene language. Sometimes 
they display vague hallucinations and delusions of a per- 
secutory character. While this form usually occurs after 
a seizure, it may precede it, in which case the convulsion 
generally clears the mental atmosphere. The attacks 
rarely last more than a few hours, but in a few cases may 
persist for a week or more. Abatement is gradual, and 
is often followed by a striking feeling of complacency, or 

B. Dreamy States. — The essential feature of these 
interesting and important conditions is a more or less 
profound clouding of consciousness. Very often they are 
preceded by transitory ill-humors, and in that case there 
is no sharp boundary line between the two. Alcohol may 
also predispose to them, even when taken in very moderate 

In pre-epileptic insanity all sorts of morbid sensory 
impressions may arise, — flashes of light, impairment of 
vision, indefinite or strange sounds, peculiar odors, and 
paresthesias, — which are not to be confounded with the 
individual aura, when such exists. There may be fixed 
ideas, falsified identifications, monotonous repetitions of 
words or phrases, involuntary or grotesque movements, 
and imperative impulses, as to strike, destroy furniture, or 
kill. In a short time — sometimes a few minutes or even 
seconds — consciousness becomes clouded, and the convul- 
sion begins. In a few cases the latter passes over into a 
pronounced dreaminess lasting for hours or days. 

Post-epileptic insanity is more common, and is charac- 
terized by deep dazedness after the seizure, lasting for 
hours or even days. Patients do not understand questions, 
speak confusedly (paraphasia), are completely disoriented, 
wander aimlessly about, collect all obtainable objects, and 


even drink their urine. While lively sensory disturbances 
are undoubtedly present, no account can be obtained from 
the patients, who have complete amnesia of all that has 
happened. As a rule, they recover their normal mental 
and emotional attitude very gradually. 

Mental and emotional disturbances, very similar to the 
above, may appear in the intervallary periods, entirely 
independent of the convulsions, and are then called 
" equivalents," or psychic epilepsy. These conditions are 
by no means rare, and are frequently observed in hospitals. 
They are more liable to occur in patients who have seizures 
at long intervals. The essential feature of psychic epilepsy 
is the disturbance of consciousness. Patients are confused, 
move and act in a mechanical or automatic manner, and 
often present evidences of illusions, hallucinations, and 
delusions. They wander aimlessly about, and do not 
appear to recognize any one, but will sometimes reply in- 
coherently to questions. Occasionally they assume fixed 
or peculiar positions, or gaze steadily at one point. In 
some instances they display a heightened excitement, 
and again a gloomy stupor, during which they may 
masturbate, expose their person, or attempt sexual assaults. 
Patients have been known to set fire to their bedding or 
furniture for such trivial purposes as boiling coffee, etc. 
The numerous criminal acts such as theft, arson, assaults, 
and even homicide, committed during these periods, demon- 
strate the extreme importance of the recognition of psychic 
equivalents, in their medicolegal aspect. The history of 
previous attacks of grand or petit mal, even if very in- 
frequent, the senselessness of the actions, with utter absence 
of motive or attempt at concealment, and either complete 
amnesia or only a very hazy recollection of what has 
happened, should make the diagnosis clear. These attacks 


usually last only a short time, — seconds or minutes, — but 
occasionally continue for an hour or more. 

Under the head of psychic epilepsy should be included 
some cases of somnambulism, occurring in epileptics. 
Patients notice only those objects which are directly in 
front of them. The eyes may be closed, half-opened, or 
staring. Movements usually display evidences of automa- 
tism, but there may be traces of deliberation and purpose, 
as in avoiding obstacles. Sometimes higher psychic fields 
are involved, and patients may carry on long conversations, 
compose poems, or transact business. Next morning 
they do not remember what they have done, but may 
complain of lassitude, stiffness, or soreness. 

In epileptic stupor the clouding of consciousness is 
intense and prolonged. Patients may eat, speak, or per- 
form certain mechanical movements, but always as if 
dreaming, and without clear understanding. Sometimes 
the eyes are closed, or the facies dazed or staring. The 
same attitude is maintained for hours or even days, and 
the expression justifies the inference that confused terroriz- 
ing delusions dominate the emotional sphere, although 
occasionally the demeanor indicates happiness or religious 
ecstasy. Patients show absolute indifference to their envi- 
ronment, never answer questions, remain in bed, and soil 
themselves. They sometimes show active resistance if dis- 
turbed, may make sudden impulsive attacks, and instinc- 
tive suicidal attempts are not infrequent. The reflexes are 
abolished, sensibility is blunted, and in single cases a tem- 
porary catalepsy is seen. Nourishment is often refused, 
either wholly or partially. 

Epileptic stupor usually lasts one or two weeks, but in 
severe cases the course is longer. Recollection of the events 
is largely or completely lost. Resolution is generally grad- 


ual, but in a few cases the confusion may disappear in one 
day. Where attacks are repeated and prolonged, patients 
may remain for a long time inattentive and dull. 

Anxious Delirium. — This form is more frequent than 
stupor, may occur independently of seizures, and the men- 
tal disturbance is profound. The attack develops suddenly, 
and may be preceded by very brief periods of ill-humor, 
characteristic sensations, and numbness, or by fixed and 
regularly recurring hallucinations, as red objects, flames, 
etc. Apprehension is dulled, surroundings are changed, 
and orientation is lost. The hallucinations and delusions 
are usually terrifying ; patients must be punished, must 
die, are surrounded by devils, animals, or throngs of people 
who come out of the walls or floor. They wade in blood, 
their parents are perishing, the house is blown into the air, 
or everything is sinking. Sometimes God or Christ appears 
and carries them in splendid chariots to Heaven ; but these 
transports are only transitory, and the predominant tone 
of their emotions is one of fear and dread. Patients are 
impelled to brutal and incredible outrages, as cutting up 
their parents or children, shooting, stabbing, etc. They 
run away to escape the horrors which confront them. 
With flushed face, either silent, or howling and shrieking, 
they rage furiously, with prodigious strength, destroying 
everything within reach. 1 

The duration of anxious delirium varies from a few 
hours to two weeks. Sometimes consciousness clears up 
suddenly after a long sleep, but usually gradually, so that 

1 One of my patients in his wild furor always ran up and down the hall, 
screaming, and striking every one in his way, and displaying such enormous 
strength that it required six men to control him. His attacks recurred regu- 
larly every six months, lasted about twelve hours, and were followed by a 
profound sleep. On awakening he remembered nothing of what had hap- 
pened. A recent case died from exhaustion on the ninth day. 


transitory hallucinations, delusions, and normal ideas are 
mixed together in a characteristic manner. There is no 
recollection of events occurring during the height of the 

Conscious delirium is a rare form, which either fol- 
lows a seizure or appears as a psychic equivalent. Patients 
appear from their conduct to be conscious, but in reality 
the apprehension is greatly clouded, while numerous illu- 
sions and hallucinations may inspire false ideas of danger. 
Expansive ideas are not uncommon. Answers to simple 
questions are coherent and relevant, but the whole de- 
meanor, if closely observed, discloses some confusion and 
disorientation. The disposition is irritable, usually anxious, 
but sometimes elated, and delusional ideas often lead to 
impulsive acts. Legrand du Saulle reports the case of a 
merchant, who, on suddenly recovering from an attack, 
found himself on the way to Bombay. Others have com- 
mitted, with seemingly unclouded consciousness, senseless 
and even criminal acts (thefts, arson, rebellion, desertion, 
indecent assaults) without any insight into their signifi- 
cance. Attacks of conscious delirium may last for days, 
weeks, or even months, and there may be a series of attacks 
separated by short intervals. 

Dipsomania in many respects resembles epilepsy, as it 
presents an apparently paroxysmal and periodical impulse 
to senseless alcoholic excesses. Among the prodromal 
symptoms are noted uneasiness, anxiety, fear, despondency, 
weariness of life, increased irritability, a feeling of heavi- 
ness in the head, anorexia, insomnia, and occasionally sex- 
ual excitement. Very rapidly after these manifestations 
there appears an impulsive and irresistible desire to obtain 
relief, which is found in a " mad rush " for liquor. Some 
patients develop a typical epileptic dreamy state, in which 


they become abusive, aggressive, noisy, and undertake fool- 
ish journeys. One man had attacks once in two years, 
when in the space of two days he would drink several pints 
of whiskey, ultimately becoming completely unconscious, 
and often, on coming to his senses, finding himself hi 
strange places. After several of these attacks he arranged 
that friends should take him to a hospital on the first 
appearance of the prodromes. 

Some dipsomaniacs present no typical epileptic disturb- 
ances, but in their attacks fall suddenly into a condi- 
tion resembling inebriety, in which they continue without 
interruption — day and night — to drink large quantities 
of beer, wine, gin, or spirits, until they have spent their 
last cent, and even sold their clothing to obtain means for 
the gratification of their morbid appetite. During these 
attacks intoxication is seldom complete, but consciousness 
is clouded, and patients retain only a hazy recollection of 
a few events of their debauch, but often manifest deep 
contrition, and an abhorrence of alcohol. Convalescence 
is gradual, and sometimes accompanied by nausea, ano- 
rexia, gastric catarrh, unsteadiness, and tremors, while a 
few cases present symptoms of collapse, accompanied by 
delirium and hallucinations. 

The attacks may recur without any external cause, and 
in the intervals, which may last for weeks, months, or 
even years in a few instances, patients have no craving 
for alcohol, and either totally abstain or drink very mod- 
erately. There are many transitions or variations from 
the characteristic picture of dipsomania. Some patienta 
manifest a disposition similar to that of epileptics, and a 
few perhaps present during life only one instance of an 
epileptic dreamy state accompanying an attack of inebriety. 

Diagnosis. — The diagnosis of epileptic insanity is gen- 


erally easy as soon as we can establish the existence of 
the characteristic convulsions. We must differentiate it 
from hysteria, dementia paralytica, and the catatonic form 
of dementia praecox. 

In hysterical insanity consciousness is less deeply dis- 
turbed in the seizures, and we almost never see sudden 
involuntary falls, serious injuries, or biting of the tongue. 
The seizures are also specially induced by external influ- 
ences, as mental emotions, physician's visits, etc., and 
may be curtailed or suddenly aborted by very lively excite- 
ment or strenuous treatment. The development is more 
diversified than that of the epileptic seizure, which is 
always uniform. In hysteria, tonic and clonic muscular 
contractions of the entire body, convulsions of the dia- 
phragm, opisthotonus, jactitation, rolling on the ground, 
somersaults, lively movements of expression (dramatic 
and passionate attitudes), alternate even in the same 
attack, and consciousness is never abolished. Dilatation 
and immobility of the pupils, usually considered an impor- 
tant characteristic of epilepsy, have recently been found 
in hysteria. 1 

In hysteria we find extravagant caprices, rapid changes 
of disposition, and dependence on external influences, 
while in epilepsy there is a rough irascibility, a limited 
waywardness, an independent periodicity, and a prominent 
ill-humor. Mental weakness is more frequent and pro- 
nounced in epilepsy. 

In epilepsy coming on in middle life, we must consider 
the possibility of dementia paralytica, which sometimes 
begins with epileptiform seizures. Here the consideration 
of the other symptoms, such as impaired pupillary reflex 

1 Karplus, Jahrbuch der Psychiatrie, XVII, 1 ; Westphal, Berliner klin, 
Wochenschrift, 1897, 47. 


and inequality, characteristic speech disturbances, ataxia, 
incoordination, etc., will soon clear up the diagnosis. 
When, however, the epileptiform attacks occur at long 
intervals, and are accompanied by one or more of the 
above symptoms, we should be prepared for the possibly 
gradual development of dementia paralytica. 

The epileptic dreamy state has been mistaken for the 
initial stage of the catatonic form of dementia prmcox. 
In the latter we find negativism, passive resistance, sense- 
less answers, rapid and correct execution of commands, 
'eccentricities, and stereotypy, with absurd acts, and less 
disturbance of apprehension and orientation. In epilepsy 
there is anxious resistance with indifference to orders, 
and uniformity of conduct, while there are frequent 
assaults, atrocities, and attempts to escape. Special 
weight attaches to the previous history and the proof 
of separate attacks of vertigo or syncope, periodical 
ill-humor, and probable night attacks, as evidenced by 
occasional enuresis, injuries to the tongue, and severe 
lassitude or headache in the morning. 

The diagnosis of the dreamy states, when only one con- 
vulsion has been observed during life, or perhaps not even 
one, but only a brief syncope, presents some difficulties ; 
but we must remember that while the convulsion is a very 
important symptom of epileptic insanity, it may be absent, 
or replaced by an "equivalent." Hence the periodicity 
of the attacks, clouding of consciousness, morbid impulses, 
the crimes committed without motive or attempt at con- 
cealment, the amnesia, and rapid course will facilitate the 

Prognosis. — This depends essentially on the cause of 
the epilepsy and the time of onset. When dependent on 
gross brain lesions, recovery is out of the question, and the 


mental weakness often progresses to complete deteriora- 
tion. When following head injuries, some recoveries have 
occurred, and in many cases decided and long-continued 
improvement has resulted. 1 

Genuine epilepsy may disappear spontaneously, but re- 
currence is common if life is prolonged, and in the inter- 
val there is usually some mental dulness with transient 
ill-humor. Improvement rarely occurs in cases where the 
dreamy states, especially stupor, have occurred, if they 
have been at all frequent. In some cases of anxious 
delirium death occurs from exhaustion. Conscious deli- 
rium is not dangerous to life, but, like anxious delirium, 
if recurring at short intervals, tends to hasten the prog- 
ress of deterioration. 

In epilepsy arising late in life, the outlook is very un- 
favorable. On the other hand, in alcoholic epilepsy treat- 
ment is often successful in effecting a cure, or at least 
great improvement. On the whole, while in some cases 
patients may improve sufficiently to go home, especially 
where the disturbance is largely in the emotional sphere, 
the prognosis of epileptic insanity is unfavorable, and 
patients should be subjected to prolonged observation and 
treatment before we assume the risk of discharging them 
from the hospital. The more so, as attacks of furor may 
occur without any seizures, and thus the patient becomes 
a danger to the community. As far as life is concerned, 
we must remember that serious and even fatal injuries 
may result from accidents occurring during the convul- 
sions, or from the development of status epilepticus. 

1 A small proportion of cases, after years of epilepsy, develop a spastic 
condition, almost approaching spastic paraplegia, with exaggerated reflexes, 
spastic gait, incoordination, etc. These cases are accompanied by extreme 
mental dulness, practically amounting to permanent stupor. 


Worcester found that sixty per cent, of epileptics die as 
the result of their seizures. 

Treatment. — When we consider that nearly twenty-five 
per cent, of all epileptics are descended from an intemper- 
ate ancestry, we must urge upon all physicians the great 
importance of combating the use of alcohol, which not 
only impairs the mental and physical powers of the par- 
ents, but imposes a terrible and unjustifiable burden on 
their offspring. To prevent epileptic insanity, we must 
begin with the ancestors. In all cases where insanity 
develops in epileptics, patients should be committed to a 
hospital, not only for their own benefit but that of the 

In cases where there are undoubted cranial injuries or 
focal diseases, if not of too long standing, a causative treat- 
ment should be tried, as trephining, excision of scars, 
removal of tumors, antisyphilitic treatment of gummata, 
etc. Usually the results are only transitory, even in 
cases undoubtedly following head injuries; and after a 
long duration of the malady the prospect of permanent 
cure by excision of scars or removal of fragments of bone 
is very slight. This experience indicates the continuance 
or gradual development of a general epileptic alteration 
in such brains. On the other hand, a long-continued im- 
provement may result from simple ventilation of the brain 
by trephining, without any further encroachment on its 
substance. Any sources of reflex irritation, as nasal polypi, 
carious teeth, ingrown toe-nails, and the like, should be 

The nutrition should be fostered by careful attention 
to the state of the alimentary system, and the diet care- 
fully regulated. To exert a permanently favorable in- 
fluence on metabolic assimilation, and particularly to 


prevent the excessive increase of uric acid, Haig gives 
practically a vegetable diet, — milk, farinaceous puddings, 
and vegetables, — and prohibits meat, bouillon, tea, and 
coffee. Agostini recommends a more varied diet, as he 
thinks a strictly vegetable diet will cause injurious 
stomach troubles. Notwithstanding the various views on 
this subject, on the whole there is a positive benefit in 
the avoidance of an excessive meat diet. 

The reduction of salt has been recently suggested, not 
only to diminish the irritability arising therefrom, but 
to enable us to materially decrease the amount of bro- 
mids. It is said that this method diminishes by one- 
half the chance of bromin poisoning. At the Craig col- 
ony for epileptics a dietary largely composed of milk, eggs, 
potatoes, farina, rice, chicken broth, boiled or roasted beef 
unsalted, etc., has been tried with excellent results. An 
occasional meal with a small and definite (6-8 grains) 
amount of salt may be given. The kidneys require atten- 
tion, and the secretion of urine should be stimulated by 
copious draughts of water or other innocuous remedies. 
In selecting forms of physical exercise, care must be used 
to avoid undue strain on the heart. The skin should be 
kept in good condition, and occasional hot baths employed 
to induce perspiration. 

It is very important to insist upon complete and perma- 
nent abstinence from alcohol in all cases, and not merely 
in alcoholic epilepsy and dipsomania. Every epileptic is 
more or less intolerant of its effects, very severe mental 
and emotional disturbance occasionally results from its 
use, and nothing is to be gained from it in any case. In 
dipsomania, absolute abstinence is the only available 
remedy. In many cases not only do the dangerous ill- 
humors become harmless, but less frequent, and finally 


disappear. In addition to careful attention to the bodily 
health and avoidance of irritants, suitable occupation, 
preferably in the open air, is a valuable adjuvant. While 
innumerable remedies have been used to control or abort 
the seizures, their utility is somewhat doubtful, since the 
convulsions are practically safety valves, which allow the 
elimination of toxins. Unless the cause can be removed, 
it is perhaps better to allow the insane epileptic to have 
his fits, as they often clear the mental atmosphere. Never- 
theless, in the present state of medical and lay opinion, 
it is advisable, in every case, at the beginning, to admin- 
ister the bromids, either singly or in various combina- 
tions, with proper precautions, until after due trial we 
can decide from the general condition of each patient — 
mentally, emotionally, and physically — whether or no it 
is best to continue their use. They should be given at 
the start in very small doses (6-8 grains) three times 
daily, after meals, in plenty of water, gradually increasing 
the amount until the point of saturation is reached, which 
is indicated by the disappearance of the throat reflex. 
Then the dose, which varies with the individual, should 
be reduced more or less gradually until we establish a 
norm which can be continued for a long time, even years, 
with occasional short interruptions. In single cases the 
epileptic disturbances disappear, not even returning when 
the medicine is suspended, and we may perhaps regard 
the case as cured. It must be borne in mind, however, 
that in a certain number of cases the seizures cease spon- 
taneously without any treatment, not to recur for years, 
if ever. Hence we must not attach too much importance 
to the curative power of the bromids. 1 

1 In the writer's experience it has been found that the fewer insane epi- 
leptics who take bromids, and the smaller the dose, the less irritability, vio- 


Should bromism occur, as evidenced by acne, digestive 
disturbances, bronchial disorders, cardiac weakness, aboli- 
tion of the reflexes, anaesthesias, impairment of memory, 
stupor, etc., the bromids should at once be discontinued, 
and an eliminative and supporting treatment instituted, 
— free and regular evacuations of bowels and bladder, 
promotion of normal skin action, and the use of digitalis 
and strychnin in small and decreasing doses, supplemented 
by absolute rest in bed, and a simple, easily digested diet. 

Among the other countless remedies employed to control 
the seizures may be mentioned argenti nitras, brom-ethyl, 
atropia, oxid of zinc, borax, adonis vernalis, and the 
Flechsig treatment by a regular course of opium in in- 
creasing doses, followed by bromids, with rectal lavage, 
and strict confinement to bed. While all these have given 
satisfactory results in some cases, none are so generally 
useful as the bromids, but may be tried where the latter 

The status epilepticus is not very frequent in insane epi- 
leptics. When it occurs, compression of the carotids should 
be tried, if the arterial tension is excessively strong ; and 
enemata of chloral hydrate, morphia, and bromids should 
be administered. Prolonged hot baths are also of value. 

Finally, in view of the liability to injuries and the ten- 
dency to sudden violent impulses, every epileptic should 
be under constant surveillance at all times, night and 



Fere*, Les Epilepsies, 1890. 

Marinesco et Serieux, Essai sur la pathogenie et traitement de 
Pepilepsie, 1895. 

lence, noise, and destructiveness there is. Reduction of the number of 
seizures has not apparently diminished the frequency of attacks of transi- 
tory ill-humor or dreamy states. 


Roncoroni, Trattato clinico dell' epilessia con speciale riguardo alle 

psichosi epilettiche, 1895. 
I. Voisin, L'epilepsie, 1897. 

Agostini, Eivista sperimentale di freniatria XXII, 267. 
Haig, Brain, 1896. 

Krainsky, Allgem. Zeitschr. f. Psy. LIV, 612. 
Cabitto, Eivista sperimentale di freniatria XXIII, 36. 
Spratling, Craig Colony Eeports, 1899. 


Hysterical insanity is a psychosis arising from a psy- 
chopathic constitution, characterized by great instability 
of the emotions, defective will poiver, and heightened self- 
consciousness, upon which there appear, ivith great ease and 
rapidity, crises or attacks with a great variety of mental and 
physical symptoms, including dreamy states, anaesthesias, 
paresthesias, paralyses, convulsions, and anomalies of 

Etiology. — Hysteria develops upon a morbid constitu- 
tional basis. Defective heredity occurs in seventy to eighty 
per cent, of cases. An equally important factor is the in- 
fluence of defective education and training. Other factors 
are trauma, shock, acute and chronic diseases. Mental 
stigmata are often recognized in early life, as irritability, 
waywardness, indolence, talkativeness, undue piety, and 
sudden and rapid changes of emotional attitude. Some- 
times such physical disturbances as chorea, headache, and 
defective speech have been noted. More than two-thirds 
of the patients are women. In children, 1 in whom the 
disease is more prevalent among males, individual symp- 
toms may be more prominent, as mutism, reflex convul- 
sions, paralyses, and attacks of screaming, convulsive 
coughs, and dreamy states. 

The role played by the disturbance of the female sexual 
organs in the production of the disease is not clear. On 
the one hand, we have the observations, that disturbances 

1 Bruns, Die Hysterie im Kindesalter, 1897. 
2 a 353 


of these organs do produce severe physical and mental 
disturbance without creating hysterical symptoms, that 
the disease sometimes appears long before puberty, and 
finally that it develops in individuals with normal sexual 
organs. On the other hand, we know that frequently 
uterine disturbances are present, and that their relief, as 
well as the removal of the healthy organs, may bring about 
a marked improvement. For these reasons it seems prob- 
able that disturbances of the female sexual organs act only 
as prominent exciting causes. 

Pathology. — The nature of the disease is still unknown. 
Some investigators hold that, primarily, the disease is not 
an affection of the brain. Biernacki, judging from his 
investigations into the condition of the blood, believes 
that the cause of the disease may be found in its defec- 
tive oxidation. Vigouroux places hysteria with epilepsy 
and periodical insanity, regarding them all as due to a 
gouty disturbance of metabolism. These explanations 
appear inadequate and inconsistent with our clinical and 
etiological experience, because they overlook both the inti- 
mate relation of hysteria to other forms of psychopathic 
degeneracy and the apparent psychical origin of the indi- 
vidual symptoms. 

Charcot and his followers and many other investigators 
look upon the disease from the side of the psychical phe- 
nomena. They, in investigation of the paralyses, the vari- 
ous sensory disturbances, and the dual personality, have 
ascertained by means of ingenious experiments that parts 
apparently devoid of all feeling can release ideas and move- 
ments without making an impression upon consciousness, 
and further that such reflexes result in movement more 
rapidly than those which are voluntary and conscious. 
Janet speaks of a disruption of consciousness in the sense 


that different fields of sensory experience can lose connec- 
tion with the states of consciousness. Sollier has recently 
accepted a partial sleepy state, a hysterical somnambulism, 
basing his conception on the fact that just as in sleep 
many impressions influence our dreams and movements 
without arousing any conscious perception or ideation, so 
in hysterical states, while part of the brain sleeps, there are 
sensory fields which receive and react to stimuli. The same 
applies in the production of paralyses in the motor field. 

The shortest and best explanation is that offered by 
Moebius, who characterizes hysteria as a congenital mor- 
bid mental state, in which diseased conditions of the body 
are produced by ideas, to which should be added the 
statement that these ideas are strongly emotional and 
sometimes of an indefinite content. This accounts for 
the fact that the physical disturbances do not always cor- 
respond to the character of the stimulus or to the content 
of the ideas, that they can appear in fields not accessible 
to the influence of the will, and, in fact, that sometimes 
they are not even noticed by the patients. These are 
well-known facts, and are recognized as physical accom- 
paniments of the feeling. The internal relation between 
sadness and tears is no better understood than that be- 
tween fright and hemianesthesia. Terror can cause a 
movement of the bowels and whitened hair, just as hys- 
teria can produce edema and disturbances of the heart's 
action. Even clouding of consciousness may be brought 
about by states of feeling ; while it must be confessed that 
hysteria cannot be entirely explained in this way, yet it 
seems probable that the increased emotional excitement 
and the greater prominence of the involuntary expressions 
which accompany it play an important r&le in the pro- 
duction of the disease. 


There is no known anatomical pathological basis for the 

Symptomatology. — The symptoms are divided into the 
psychical and the physical. The psychical symptoms first 
described are those characteristic of the psychopathic basis 
and are continuously present, occupying what many writers 
call the interparoxysmal period, while the dreamy states 
characteristic of the crises or attacks occupy, according to 
them, the paroxysmal period. 

Psychical Symptoms. — Apprehension presents no strik- 
ing disturbances, in fact, many patients are unusually sensi- 
tive. They have a keen perception for details, and espe- 
cially for any defects. A few patients show unusual gift 
in some fields, especially scientific. Often a striking 
feature is lack of sound judgment, although the patients 
appear vivacious and bright upon superficial examination. 
They are easily attracted by anything new or striking, 
become the clients and champions of the most recent 
physician, and adopt peculiarities in dress and ornament. 
This is especially true in the field of religion. They enjoy 
anything sensational, and take pleasure in gossip and in 
all sensuous enjoyments. 

The memory, although occasionally one-sided, is unim- 
paired. That which is perceived is not always correctly 
interpreted. In some cases there is a tendency not only 
to amplify events of the past, but even to distort them 
by pure fabrications, and this is especially noticeable 
in attempts to elicit sympathy and create sensation. 
Startling statements without any foundation are often 
rehearsed to the physician. One patient described in full 
an epileptic attack from which, in reality, she never 
suffered, and another told of a trance of three weeks' dura- 
tion, during which she knew nothing. It is sometimes 


difficult to say how much of this is intentional deception, 
and how much is due to the subjugation of memory to a 
lively imagination. In some cases, no doubt, the imagi- 
nation dominates entirely all thought and action without 
creating the picture of a real delusion. 

The disturbance of the emotional attitude is a most 
prominent element. Its fluctuation determines to a large 
extent the whole mental life of the patient. Normal con- 
trol is wanting : the patients are excitable, are responsive 
to everything, are impelled to take a personal interest in 
everything in their environment, and there is a tendency 
to show emotional outbursts at very trivial affairs. Occa- 
sionally there is heightened sexual excitement, which may 
lead to debauchery. Frequent and abrupt changes in the 
emotional attitude are characteristic. One never knows 
where to find the patients: they pass abruptly from a 
state of merriment into passionate anger ; at one moment 
they may be distastefully sentimental, at the next crotchety 
and antagonistic. This increase in the emotional excita- 
bility is probably a cause of the concentration of thought 
upon self. The more quiet contemplation of external 
affairs is disturbed by an excitable emotional tone the 
more strongly is the attention attracted to self, and in 
this way the patients become self-absorbed. Some even 
derive pleasure in meditating over their own ill health. 

In this way hypochondriacal ideas originate and gain 
prominence; trifling feelings of discomfort receive exag- 
gerated attention, and may give rise to the sensation of 
great pain. Any genuine complaints are greatly exag- 
gerated by the imagination of the individual until hypo- 
chondriacal ideas are evolved. Real pain arising from 
any cause fails to disappear with the removal of the cause, 
but continues indefinitely, and may even increase in inten- 


sity. The headache, backache, and perhaps vertigo, coin- 
cident with menstruation or with anaemia, may be the 
nuclei from which there arises a malady, the symptoms of 
which the patients rehearse with great clearness and in all 
detail on every possible occasion. 

The patients develop a most remarkable attitude 
toward their disease, about which their whole life seems 
to centre. They become fond of and even proud of inva- 
lidism, finding in it a source of entertainment. This be- 
comes the more evident in the failure of cooperation in 
treatment. Although complaining bitterly, they lack all 
feeling of personal responsibility in carrying out treatment, 
and may even stubbornly refuse to help. However, any 
new or striking method of treatment, although it entails 
some suffering, will be undertaken for the sake of publicity. 
Many continue to enter into the enjoyments of life, 
attend entertainments, and receive much company, in 
spite of the claim that their suffering is even enhanced 
by such endeavors. 

Very often morbid ideas cause anxiety and despair; 
terrible thoughts constantly torture them; ungrounded 
fears, frightful dreams, alleged hallucinations, — sexual 
assaults, ghosts, assassins. These are depicted on every 
occasion with great show of emotion, but not without 
emphasizing their own heroic struggle and martyrlike 
submission. Occasionally they utter threats of suicide, 
to end their miserable existence, sometimes even making 
melodramatic attempts, such as tying a ribbon about the 
neck or jumping into shallow water. One patient drank 
a small quantity of shoe blacking, and claimed to have 
swallowed several pins. 

Some patients demand early and constant medical 
attendance, and cannot be satisfied unless they have regu- 


lar daily visits and prompt response to hurried calls in 
the intervals. In this way some patients develop a state of 
absolute dependency upon one physician. On the other 
hand, it is not unusual for them to change frequently from 
one physician to another, visit celebrities, and ask for 
many consultations. Often in going the round of physi- 
cians they fall into the hands of quacks who pamper and 
gratify them by offering some wonderful cure, which, how- 
ever, is as transitory as it is striking in its results. 

The patients are markedly self-conscious , and display 
a corresponding lack of regard for other and common 
interests. They perceive with morbid acuteness any en- 
croachment upon their own comfort, but accept the most 
extreme sacrifice on the part of others as a mere matter 
of course. They are always exacting beyond reason, 
dissatisfied with the best efforts of others, and deeply 
grieved over neglect or lack of sympathy. The insatiable 
wants of many hysterical patients develop as the result of 
this heightened self -consciousness. Dissatisfied with what 
they have, they are constantly asking for something new, 
usually things difficult to obtain ; new furniture, new 
quarters, new clothing, different food, etc. It is often sur- 
prising to see how undeserving patients successfully establish 
intimate relations with churches, societies, and well-mean- 
ing philanthropists, who gratify the most unreasonable 
demands. They regularly tyrannize over the family. 

In the domain of will there is an increased susceptibility 
to external influences. The patients yield readily to evil, 
and rapidly become enthusiastic in any cause. Yet at 
times they may be extremely obstinate and headstrong 
in their purposes. Some subject themselves to pain and 
great discomfort, and even torture for insufficient reasons, 
refusing to take nourishment or perhaps to speak. This 


apparently opposite state of the will in reality arises from 
a pliancy to accidental influences; sometimes external 
sensations, at others personal fancies. 

Impulsive actions arise from the same source, being the 
result of a sudden outburst of the emotions, or of a pleas- 
urable inclination. The conduct of the patients in conse- 
quence of this is unstable and erratic. They change 
rapidly from one purpose to another, without sufficient 
reason, and may even present some restlessness which 
stands out in strong contrast to their physical weakness 
and helplessness, and they long for adventure. In manner 
they are at times vivacious and frank, at others reserved 
and bashful, or again silly and sentimental. They are 
demonstrative and often express themselves in the most 
exaggerated terms. Their vehemence of expression by 
no means always corresponds to the intensity of the 
emotion, as the latter often fluctuates rapidly from one 
state to another. The patients characterize their own con- 
dition by such expressions as, most horrible, excruciating, 
inexpressible; and in depicting their suffering it is not 
unusual for them to add color to the description by copi- 
ous weeping or even fainting. In spite of this intense 
misery the thought of self-enjoyment usually remains in 
evidence. One patient, after filling several sheets of her 
home letter with the most horrible self-imprecations, 
closed with the request for macaroons. 

The capacity for employment is impaired, the patients 
have no disposition for earnest and strenuous occupation, 
lack perseverance, are weak and easily exhausted, and 
always feel that they must spare themselves. On the 
other hand, they pass much time with trifles, arranging 
and rearranging pretty ornaments in the rooms, dilly- 
dallying with their toilet and personal adornment. 


These mental symptoms of hysterical insanity give only 
a general picture of the psychical disturbance. Individual 
cases always present their own peculiarities, in which there 
is usually a predominance of one set of symptoms. Some 
investigators claim that these psychical symptoms really 
have nothing to do with hysteria, but are only a part of a 
degenerate state which may or may not be associated with 
hvsteria. There can be no doubt but that characteristics 
of degenerate states appear in various hysterical manifes- 
tations. The basis of hysteria lies in poor hereditary en- 
dowment and defective development, from which it seems 
impossible to dissociate the characteristics of the psychic 
states, which really form a part of the same disease pic- 
ture. In view of this conception, it is impossible to dis- 
tinguish between the hysterical and the degenerate states 
by neurological data alone. A difficulty seems to arise in 
the mild cases, in which the neurological symptoms are 
unaccompanied by the psychic symptoms characteristic of 
hysterical insanity. A similar condition, however, exists 
in epileptic insanity, where the mild cases fail to present 
the characteristic psychic symptoms. 

Physical Symptoms. — The physical symptoms of hys- 
terical insanity are more readily recognized, and naturally 
regarded of more importance. These functional disturb- 
ances, a detailed description of which will not be entered 
into here, are paralyses of different limbs, choreiform 
movements, contractures, localized and general convul- 
sions, aphonia, impairment of speech, numerous sensory 
disturbances, including paresthesia, anaesthesia, hyperaes- 
thesia, and visual disturbance; globus, clavus, singultus, 
fainting fits, loss of appetite, obstinate vomiting, disturb- 
ance of respiration, and anomalies of secretion. It is 
characteristic of all these symptoms that they do not fol- 


low anatomical and physiological rules, but are dependent 
in their appearance, persistence, and departure upon psychic 
influences. Hemicrania or convulsive movements can often 
be made to disappear by pressure upon the eyeballs. Con- 
tractures or paralyses may be made to vanish by firm 
pressure over the ovaries or in the hypogastric region, or 
by an unexpected dash of cold water upon the face or 
body. Patients who for years have been bedridden, reduced 
to a skeleton by fasting and secretly inflicting wounds 
upon themselves to incite sympathy, may be immediately 
transformed into an entirely different individual by a sharp 
command, new environment, or some sudden freak. But 
this transformation is usually short-lived, and the patients 
return either to their former or still more distressing con- 
ditions. A prominent characteristic often encountered, and 
which tends to substantiate the idea of feigning, is the 
disappearance of the symptoms when the patients are free 
from constraint, believing themselves unobserved, only to 
reappear as soon as their illness is referred to or when 
confronted by the physician. One is further encouraged 
in the belief that there is much dissimulation by the efforts 
of the patients to produce ulcers, to prick the gums in 
order to make bloody sputa, and to devise means of remov- 
ing the feces unobserved, in order to convince the physi- 
cian that the bowels are occluded. We would certainly 
be short-sighted if we did not see in these premeditated 
actions the expression of a disordered mind. 

Of the transitory psychic disturbances the dreamy states 
are the most prominent. These are characterized by a 
marked clouding of consciousness, of longer or shorter 
duration, which may either follow, take the place of, ter- 
minate in, or be interrupted by a convulsion. 

The patients lie quietly with relaxed limbs, occasionally 


showing a slight tonic rigidity, breathing quietly, and with 
a slow pulse rate, the eyes turned upward or rotated lat- 
erally. They are irresponsive except to a powerful stimu- 
lus, such as an electric shock or sudden terror, which 
sometimes entirely arouses them. Such a condition, inter- 
rupted by occasional convulsions and short lucid intervals, 
during which food can be taken, may last from a few 
hours to three weeks. 

Sometimes the dreamy state simulates ordinary sleep, 
when the patients become drowsy and lie down, the eyes 
close and limbs become relaxed, as in a profound sleep, with 
deep and regular respiration. It is usually of short dura- 
tion, and the patient awakes gradually with no recollection 
of the interval. 

These attacks form transition states into somnambulism, 
which occurs during the natural sleep of hysterical pa- 
tients. The patient leaves his bed, wanders about the 
room, opens the window, and does many peculiar acts, all 
of which are well coordinated. Sometimes he destroys 
clothing, hides objects, or sets fire to furniture ; later he 
returns to his bed, and arises the next morning with only 
a confused recollection of what has happened. Similar 
attacks may occur during the daytime, either independently 
or in connection with a convulsive attack, a fit of laughing 
or crying. The patients then walk about, muttering unin- 
telligibly to themselves, oblivious to the environment, and 
not the least distractible, although able to avoid obstacles. 
It is very difficult to arouse them from this state, even by 
the application of powerful electrical currents. 

Another form of the dreamy state appears in connec- 
tion with the delirious excitement of a severe hysterical 
attack. There is a marked clouding of consciousness with 
many hallucinations. The patient is transported into 


beautiful surroundings, has visions of heaven, sees God 
and the angels, or undergoes frightful experiences, endur- 
ing the agony of a public electrocution, or of slaying a 
dear friend. While in this state his manner, expression, 
and movements are indicative of joy or agony. One of 
my patients in such a state of ecstasy greeted the physi- 
cian as John Ruskin, and another as the Apostle St. Paul, 
describing the beauty of her surroundings with great fer- 
vor ; another ran to escape a posse of officers, who were 
in search of her for the killing of her sister. 

In the younger patients there appears still another form 
of the dreamy state, in which the clouding of conscious- 
ness is moderate, and does not prevent a recognition of 
their environment. The patient usually exhibits a happy, 
unrestrained mood, sometimes with marked silly behavior. 
He performs all sorts of foolish, wanton pranks, screams, 
imitates the cries and behavior of animals, and scrambles 
about. The real morbidity of this apparently conscious 
behavior becomes evident when, as occasionally happens, 
it is suddenly terminated by a light convulsive seizure, 
and then, without memory of the foregoing behavior, the 
patient passes into a short period of depression. 

The memory of the events during these different dreamy 
states, as well as occasionally for events just prior to the 
onset, is always much confused, and sometimes completely 
abolished. In some cases there are encountered examples 
of a sort of dual personality, in which the recollection of 
previous attacks occurs only during subsequent ones, it 
being completely lost in the interval. It also may happen 
that during an attack a particular period of the patient's 
life is lived over again, similar to experiences in the 
hypnotic states. Such alterations in personality arise only 
under the influence of autosuggestion. 


There still remains to be described mental disturbances 
of shorter duration occurring during the course of hysteria. 
These states are characterized by a gloomy and anxious 
mood, sometimes accompanied by delusions of self-accusa- 
tion and indefinite hallucinations. Conditions of excite- 
ment arising as the result of jealousy, spite, and the like, 
more frequently appear in the form of passionate out- 
breaks with violent abuse, and sometimes a tendency to 
destroy objects, or even to smear themselves. These usu- 
ally pass off in a few hours. Sometimes they recur in con- 
nection with the menses. 

Course. — The course of the disease is usually protracted, 
sometimes extending over many years. In women espe- 
cially, the onset of the disease is early, frequently appear- 
ing at the age of puberty. In contrast to the prolonged 
course of the disease, the individual symptoms may show 
the greatest variation in appearance and prominence. One 
of the most marked characteristics of hysteria is the ra- 
pidity and abruptness with which the symptoms change. 
Usually there is a series of attacks which last but a few 
hours or a few days. Yet when one considers depressed, 
excited, and dreamy states, and physical disturbances, there 
is usually a variegated picture extending over considerable 
time. The course of the disease in children and in men 
is apt to be far more uniform, with little variation of the 
individual symptoms. 

Diagnosis. — The diagnosis is far more difficult in hys- 
teria in the male, and especially in differentiating the 
constitutional psychopathic states. In the latter the course 
is more uniform, and the dreamy states and various physi- 
cal symptoms are not encountered. The traumatic neuroses 
are characterized by a far more uniform development. In 
differentiating congenital neurasthenia it must be remem- 


bered that it presents only psychical symptoms. The differ- 
entiation from epilepsy has received sufficient consideration 
under that disease. 

Prognosis. — While the prospects are good for the dis- 
appearance of the several attacks, it is not as favorable 
for the future of the patient, who is very apt to suffer 
from a recurrence of the same, or other hysterical symp- 
toms, on later occasions. Hysteria in children is de- 
cidedly more hopeful, as the symptoms usually disappear 
with development, leaving perhaps only a weakened power 
of psychic resistance. Occasionally remarkable cures are 
effected by the removal of prominent exciting causes, as 
diseases of the sexual organs, injurious environment, and 
improper hygiene. In male patients hysteria with hypo- 
chondriacal complaints is resistive to all modes of treatment. 

Treatment. — The disease, developing as it does upon a 
psychopathic basis, demands prophylaxis in the way of 
care of the pregnant mother, and careful supervision of 
the education and training of children of psychopathic 
parents. The pregnant neurotic mother should avoid all 
forms of excitement and sources of fear and worry, and 
conform as closely as possible to a life of mental equa- 
nimity. The child, especially if it shows a tendency to 
insomnia with night terrors, or restlessness and evidences 
of unnatural excitability and precocity, must be removed 
from the presence of a hysterical mother, who is naturally 
least fitted for its training. Such pernicious environment, 
where the child is subjected to emotional outbursts and 
fits of temper, and besides must witness other hysterical 
symptoms, has an indelible effect, particularly in the 
formative period between the fifth and twelfth years. 

Relieved of such surroundings, the main object in the 
education should be the development of physical strength 


and vigor, and the maintenance of an effective state of 
nutrition. For this purpose, plenty of out-of-door exer- 
cise, with an abundance of sleep and wholesome diet, must 
be prescribed in connection with a discouragement of all 
elements of precocity in the mental, moral, and sexual 
life, and inculcation of self-control and the nobler senti- 
ments. The same care must be continued during the 
period of puberty and youth, but should include advice 
in relation to sexual matters, sentimental love affairs, and 
later to the assumption of the duties of early married life, 
especially sexual relations. 

In the treatment of the disease itself the element most 
essential to success lies in the personality of the physician, 
who must inspire the patient with confidence, and secure 
the cooperation of the family. Except in the lighter 
cases, it is of first importance to isolate the patients and 
establish a suitable routine in the mental and physical 
life, thereby removing from the environment the disturb- 
ing factors which have always been a source of annoy- 
ance, and have acted as exciting causes. This isolation, 
although best carried out in a small, well-selected sani- 
tarium, under the direct supervision of a physician, can 
be accomplished, with the aid of an efficient nurse, at the 
home. At all events the patient must be given over entirely 
into the hands of the physician, who establishes confidence 
and control, not by harsh and dogmatic opposition, but by 
gentle persistence, in which he must combine firmness 
and even boldness. This accomplished, he is in a position 
to bring about great improvement, and often recovery, by 
simple remedies. Attention should be directed to any 
possible organic disturbances in the stomach, intestines, 
kidneys, heart, lungs, and sexual organs. Iron should 
be prescribed in anaemia, and restoratives employed in 


conditions of emaciation, as well as bitter tonics for 

On the other hand, mechanical' therapy must be relied 
upon to produce the best results. Of the mechanical 
measures the most important are hydrotherapy, electricity, 
massage, exercise, and employment. In the use of hydro- 
therapy Collins regards the tonic bath the best, in which 
the water, at a temperature varying from fifty-five to sixty 
degrees is applied under from fifteen to twenty pounds 
pressure for from four to five seconds, followed by a Fleury 
spray of eighty degrees and similar pressure, for one to 
two seconds. In the use of the bath hysterogenic zones 
must be protected. The reaction should be facilitated by 
passive movements, walking, or gymnastics, for one half- 
hour following the bath. Where this bath fails to 
produce the desired effect, or is not well borne, he 
suggests the use of the Scottish spray. It is always 
desirable, when possible, to avail oneself of a hydriatic 
institution for these purposes. The treatment can be 
accomplished, however, in the house supplied with water 
under sufficiently high pressure by the simple use of a 
detachable hose and a tube. This should always be under 
the direct supervision of the physician, who will find it 
necessary to vary the details of the treatment according 
to individual cases. When the bath is not accessible 
the drip sheet may be used, the description of* which may 
be found under the treatment of acquired neurasthenia. 

In the application of electricity the faradic current is 
of most service in improving the nutrition and in reliev- 
ing anaesthesia and hyperesthesia. 

The daily routine of the hysterical patient should be 
one of activity, alternating with rest and relaxation, 
including massage, gymnastic, and out-of-door exercise, 


combined with some sport which tends to increase self- 

There are a few cases which require surgical treatment 
for the alleviation of organic disturbances in the sexual 
organs, especially where the symptoms of the disease 
seem to bear a definite relation to the menstruation. 
Removal of slightly diseased or even normal ovaries have 
produced improvement in a few cases, but it is the gen- 
eral verdict of to-day that this drastic procedure has 
more often been of detriment than benefit, and should be 
discarded. 1 

Hypnotism is of limited value, because those suscep- 
tible to hypnotic suggestion are apt to be influenced by 
any powerful suggestion that happens to be presented. 
Furthermore, hypnotic experience brings about an unde- 
sirable dependency of the patient upon the physician, 
which makes impossible an effective subjugation of their 
own wills in the strife with the morbid influences. The 
greater the influence exerted, the more easily autosug- 
gestions arise, and the quicker the efficacy of the hypnotic 
suggestion is nullified by other and opposing ideas. In 
mild cases, and especially in children, suggestive therapy 
is of considerable importance in overcoming individual 
hysterical symptoms, such as paralyses, sensory disturb- 
ances, and tremor. On the other hand, simple suggestion 
is a therapeutic measure of great value in every case, and 
often suffices for the complete disappearance of paralyses, 
contractures, aphonia, etc. 

In the treatment of the hysterical attacks, the 'patient 
can often be restored to clear consciousness by a brisk 
command, or, if this fails, by a dash of cold water upon 
the face, by the electric brush, or pressure over the ovaries 

1 Angelucci, e Pieracini, Rivista sperimentale di freniatria XXIII, 290. 


or upon the hysterogenic zones. In very severe cases 
inhalations of chloroform may be necessary. 


Moebius, Schmidt's Jahrbuecher., 199, 2, S. 185; Neurologische 

Beitraege, I. 
Pitres, Lemons cliniques sur l'hysterie et Phypnotisme, 1891. 
Gilles de la Tourette, Traite clinique et therapeutique de Physterie, 

Janet, Der Geisteszustand der Hysterischen, 1894. 
Sollier, Genese et nature de Physterie, 1897. 
Ziehen, Eulenburg's Realencyclopaedie, 3. Auflage. 
Collins, Treatment of Nervous Diseases, 1900. 


Traumatic neuroses is the name applied to a symptom 
complex arising as the result of trauma, characterized 
by a gradual appearance of numerous motor and sensory 
symptoms and mental depression of prolonged duration. 
The trauma may occur in the form of fright, intense 
anxiety, a fall or an accident, especially an explosion or a 
railroad accident. 

Cases of this sort were first recognized and well de- 
scribed by Erichsen in 1886, but it was not until the work 
of Oppenheim and Struempell appeared in 1889 that the 
disease was clearly differentiated and received its present 
name. The recognition of such a disease has always met 
with more or less opposition, especially from the French 
writers, and more recently from Schultze, Hoffman, and 
Mendel, who maintain that the disease is either hysteria 
or neurasthenia of traumatic origin. 

Etiology. — At present there is no adequate explanation 
of the pathology of the disease. Westphal and his school 
consider that there is an organic basis, to be found in 
changes of the central nervous system. Charcot regards 
the disease as closely related to the hypnotic conditions, 
because the disease picture wholly resembles the picture 
of a firmly rooted autosuggestion. The psychical origin 
of the disease is still the generally accepted view. This 
view is substantiated by the fact that the neurosis some- 
times appears without known injury, as when following 
fright or slight injury not received upon the head ; and, if 



received in an extremity, the manifestations of the disease 
are not necessarily limited to it, but may be general. 

In cases following head injury some contend that a deli- 
cate pathological change occurs in the cortical neurones. 
Experimentation upon test animals, in which definite 
pathological lesions in the neurones can be produced by 
concussion without severe injury, would seem to verify 
this supposition. 

It is a question whether the emotional disturbance at 
the time of the accident should be regarded as the cause, 
as very frequently weeks, and even months, elapse be- 
tween the accident and the appearance of the first symp- 
toms. An equally important factor in the minds of some 
investigators is the psychical influence of membership in 
an accident insurance society, of possible indemnities and 
suits for damages. In cases where these factors exist 
the neurosis seems to run an unfavorable course. At 
any rate the symptoms regularly worsen until settlement 
is reached, when they improve rapidly and often entirely 
disappear. Added to the emotional disturbance over the 
injury, pain and anxiety for the future, there also appears 
a desire to obtain as large damages as possible, a tendency 
to overdo misrepresentations, and to remain incapacitated 
longer than necessary, while anxiety about the trial and the 
uncertainty of the outcome, which may extend over con- 
siderable time, prevent the rest and quiet which are always 
essential to improvement. 

Another element of importance is the defective consti- 
tutional basis, in which alcoholic intemperance plays a 
considerable r61e. 

Symptomatology. — The symptoms develop gradually 
in the course of a few weeks or months following the 
shock, and consist chiefly in a condition of despondency 


with anxiety, fear and loss of the power of both physical 
and mental resistance, noticeable especially in the inability 
to undergo strain. The patients become quiet, depressed, 
apprehend with difficulty and take little interest in the 
environment. Thought becomes unusually uniform and 
sluggish, and centres about the accident, which the 
patients refer to over and over, and often describe in 
detail, laying stress upon their "hard luck," present 
deplorable condition, and hopeless future. Sometimes 
compulsive ideas and agoraphobia appear, but hypochon- 
driacal ideas are apt to be more prominent. The patients 
cannot rid themselves of thoughts of the accident, and 
believe that they have been severely injured, because they 
are not the same, are always tired, exhausted, and unable 
to work. They show a tendency to observe carefully 
everything about their physical condition which may have 
had connection with the injury. 

In emotional attitude they are very irritable, sensitive, 
and easily thrown into a state of perplexity or confusion, 
are unable to express themselves with perfect coherence, 
and always feel embarrassed by a sensation of anxiety and 
inward oppression, which may lead to passionate outbursts 
and even suicidal attempts. The memory in spite of com- 
plaints to the contrary is good, if one makes allowance for 
the lack of interest in the environment and the faulty atten- 
tion. The capacity for work is greatly hampered by hypo- 
chondriacal notions and the numerous nervous complaints. 
The psychical symptoms here enumerated usually do 
not become more prominent. Occasionally there appear 
dreamy states or acute hallucinatory excitement. Mental 
impairment, if present, is usually due to genuine head 

Physical Symptoms. — The sleep is disturbed by anxious 


dreams, the appetite is poor, and the nutrition becomes im- 
paired. The patients complain of various sensations in the 
head and back, and especially of paresthesias and pain in 
parts of the body, which may have been injured at the 
time of the accident. The pain, which is usually the 
most prominent symptom, is persistent and troublesome, 
and may lead to immobility of the parts. Besides this 
there may be ringing in the ears, loss of strength, palpi- 
tation of the heart, difficulty of urination, and sometimes 
obstinate vomiting. Some cases present objective symp- 
toms, such as areas of analgesia, hyperesthesia, constric- 
tion of the field of vision, and difficulty of hearing, also 
increase of the tendon reflexes, paralyses, slowness and 
uncertainty of movement, disturbance of gait and speech, 
and some tremor. Tremor, especially of the fibrillary 
type, is often present, being either general in character, 
or involving muscles of the paralyzed part. The paral- 
ysis may be either of the form of hemiplegia or para- 
plegia, in which the facial and hypoglossal nerves are 
seldom included. The paralysis almost always occurs on 
the same side as the accident, and is frequently accom- 
panied by contractures. There is often an acceleration 
of the pulse and sometimes of respiration following emo- 
tional disturbance, pressure on the painful points, or mus- 
cular exertion. Occasionally, also, vertigo, or even 
epileptiform attacks, may be produced in the same way. 
Localized muscular spasms and convulsions are much 
more common. Vasomotor disturbances are encountered, 
as localized blushing, cyanosis, and dermography. The 
sensory disturbances, both subjective and objective, are 
usually in the same side of the body as that on which 
the trauma was received. Of these hyperesthesia is the 
most frequent. All of these disturbances are to be dis- 


tinguished from those accompanying organic disturbances 
in the brain by their broad extent, changing condition, and 
the fact that they worsen under the influence of emotional 
and physical disturbances. To this Friedmann adds the 
further characteristic that the patients have little resist- 
ance for alcohol, galvanization of the head, and compres- 
sion of the carotids. 

Diagnosis. — The diagnosis is not only difficult, but 
sometimes impossible. The disease may be distinguished 
from hysteria by the uniformity of the symptoms in a 
given case; the patient does not present a variegated 
change of symptoms, caprice, pronounced alterations of 
disposition, and desire for undertaking something new, 
though a similar uniformity in the symptoms may exist 
in male hysterical patients. There is not the same pliancy, 
nor are the symptoms as transient as in hysteria, yet in 
this respect they remind one of a few hysterical patients 
with a persistent autosuggestion ; but even here we would 
expect to encounter characteristic hysterical attacks and 
dreamy states. In distinction from the constitutional 
psychopathic states the psychosis has a more or less sud- 
den onset, depending upon an injury, and runs a more 
favorable course. 

The greatest difference of opinion exists in reference to 
the frequency of simulation and its detection. Unfortu- 
nately the various objective symptoms, the constricted 
field of vision, the acceleration of pulse, the increase of 
tendon reflexes, and the absence of galvanic excitability, 
are of little value in establishing a positive knowledge of 
the existence of a psychical disorder. Fear of deception, 
however, is always over-estimated by the physician. It 
is useless to attempt to unmask deception by the presence 
of any one symptom or group of symptoms. The detec- 


tion of simulation must depend upon the conformity of 
the whole clinical picture to one of the known disease 
symptom groups. 

Recently the attempt has been made to prove some of 
the symptoms by means of psychological tests; as, for 
example, the power of apperception, diminution of the 
ability to figure, the susceptibility to training, and espe- 
cially fatigue. Experience with many normal persons of 
different grades of education in these particulars gives the 
necessary basis for the decision. 

Prognosis. — The lighter cases of traumatic neuroses 
which appear soon after the accident may improve rapidly, 
but even among these there are some with a long course 
and an unfavorable prognosis. Yet the duration of many 
months, or even a few years, may end in recovery or great 
improvement. The prognosis is less favorable where 
there are pronounced focal symptoms, or in the presence 
of general arteriosclerosis. 

Treatment. — The first indication is to dispel as far 
as possible all ideas of litigation. Next to this, employ- 
ment is of the greatest value. It often happens that 
the symptoms of the disease disappear rapidly as soon 
as litigation is settled, or as soon as the patients are 
compelled to go to work again. A residence in an insti- 
tution with the opportunity for employment and distrac- 
tion frequently serves to bring about great improvement 
or recovery. In all cases there should be an application 
of hydrotherapy, massage, exercise, electricity, and hyp- 
notic suggestion, as well as dietetic regimen. 


Oppenheim, Die traumatischen Neurosen, 2. Auflage, 1892. 
Schultze, Sammlung klinischer Vortraege, N. F., 14 (Innere Medi- 


cin, No. 6) . Deutsche Zeitschr. f . Nervenheitkunde, I, 5 u. 6, 

S. 445. 
Struempell, Muenchner medicinisclie Wochenschr., 1895, 49 u. 50. 
Saenger, Die Beurteilung der Nervenerkrankungen nach Unfall, 1896. 
Fuerstner, Mouatschr. f. Unfallheilkunde, 1896, 10. 
Knapp, Nervous Diseases, Dercum, 1895. 


In these psychopathic states, which include congenital 
neurasthenia, compulsive and impulsive insanity, and con- 
trary sexual instincts, the fundamental symptom is to be 
found in a continuous morbid elaboration of normal stim- 
uli. They develop upon a psychopathic basis, and in 
common present a morbid misdirection of thought, feeling, 
and will throughout life. At the same time there appears 
a mixture of the normal with the abnormal state, seen in 
the inconsistency between the clearness of thought and 
insight into propriety on the one hand, and the sudden 
unwarrantable changes of disposition and peculiarities of 
actions on the other, which gives one the impression of 
disproportion and distortion. Physical stigmata are com- 


Congenital neurasthenia is characterized by a perverted 
tone of feeling, increased sense of fatigue, distractibility, 
depressed emotional attitude, indecision in conduct, with- 
out involvement of intellect or consciousness. 

There is always present a perversion of the tone of 
feeling, and a greatly increased sense of fatigue. While 
the patients are capable of taking up a piece of work with 
intelligence and skill, they tire quickly, demand frequent 
rests, and are quite unfit for steady application to mental 
or physical work, because of resulting headache, insomnia, 
or general malaise. There is a tendency to display hypo- 



chondriacal whims. The distractibility is greatly in- 
creased, so that even the most trifling affairs in the 
surroundings may interrupt and interfere greatly with 
systematic work. 

In the field of intellect there is no striking disturbance ; 
the consciousness remains unclouded and there is coher- 
ence of thought. The patients often appreciate their un- 
fortunate condition. 

In emotional attitude they are oppressed and sorrowful. 
They may have always been especially susceptible to the 
cares, sorrows, and misfortunes of life. Present pleasure 
is always clouded by past sorrow or the troubled fears of 
the future. Any undertaking dismays them, and they 
take little or no pleasure in any occupation. They are 
easily discouraged, feel that they are of little use in the 
world, are nervous, sick, and fear the outbreak of some 
disease. Some are always encumbered with the feeling 
that they have done something wrong, or that some ill 
will befall them. They are very deliberate in the con- 
sideration of all circumstances and possible results. In 
actions they exhibit a tendency to great precision and 
punctuality in little things. Their actions also show a 
certain uniformity and lack of freedom. Some patients 
are constantly thinking of death and are always prepar- 
ing themselves for it. Though they may not seem in 
earnest about it, yet it not infrequently happens that 
they make attempts at suicide. Very often all sorts of 
nervous complaints interfere with their ability to work, 
such as pressure and pain in the head and peculiar sensa- 
tions in all parts of the body. Sleep is usually much 

Upon the basis of congenital neurasthenia there some- 
times develop conditions of pronounced depression, espe- 


cially following a mental shock, a fright, or a misfortune. 
This condition is one of simple depression without hallu- 
cinations or delusions, with retention of consciousness and 
good insight, associated with a few hypochondriacal com- 
plaints, such as pressure about the heart, discomfort in 
the stomach, and stiffness in the legs. 

The course of the disease is very prolonged, with irreg- 
ular remissions ; but within certain limits it runs a very 
uniform course, lasting from a few to several years. The 
disease first makes its appearance about the twentieth 
year. At first remissions are apt to occur, but later there 
is a tendency for the symptoms to persist, until finally 
there is a continuous morbid condition with little varia- 
tion. Even during the remissions patients always dis- 
play some evidence of mental peculiarities; they are 
quiet, dull, shy, or unfriendly. 

The cases described above represent the usual disease 
picture. Instead of predominance of the sad disposition, 
the most prominent feature may be an ill-humored, dis- 
gruntled disposition. Here there is usually a heightened 
self-feeling and perhaps also great selfishness. The 
patients are easily offended, sensitive, difficult to handle, 
distrustful, grumbling, quarrelsome. They are also apt 
to be very passionate, are easily excited, and may even 
become aggressive, and are always very susceptible to al- 
cohol. In their actions they are unstable; sometimes 
very tractable, at others stubborn. 

Sometimes patients present a marked irritability, lead- 
ing at times to attacks of blind rage with complete loss of 
self-control, especially under the influence of alcohol. 

Congenital neurasthenia presents transition forms into 
hysterical insanity and in some cases shows similarities 
to the traumatic neuroses. There is no sharp distinction 


between congenital neurasthenia and acquired neurasthe- 
nia. The greater the deficiency in the original constitu- 
tion of the diseased patient, the greater is the similarity 
to congenital neurasthenia, in which, from youth, the ordi- 
nary stimuli have been elaborated only in a morbid man- 
ner. In congenital neurasthenia there is always present 
a morbid indisposition, whether or not the individual is 
overworked, while in acquired neurasthenia there appears 
a simple irritability upon overexertion, which disappears 
with rest. In congenital neurasthenia the morbid vacilla- 
tions of the emotions, which play the important role, may 
even improve under the influence of exertion, which acts 
as a diversion, while prolonged idleness is apt to prove 

Treatment. — A well-regulated life, with choice of sur- 
roundings, can make the patients very comfortable, but 
family strife and increased responsibilities diminish the 
chance of recovery. On the other hand, absence of re- 
straint tends to increase the trouble. They very often 
need employment, which must be suited to them, and so 
adjusted as to gradually increase the responsibility and 
the exercise of strength. Both massage and gymnastics 
are of value in creating new energy for work and in estab- 
lishing self-dependence. Hypnotic suggestion is often 
helpful in cases with insomnia and complaints of pain. 


Saury, JCtude clinique sur la folie hereditaire (les degeneres), 1886. 
Binswanger, Die Pathologie und Therapie der Neurasthenie, 1896. 
Krafft-Ebing, Nervositaet und neurasthenische Zustaende, 1895. 


In this psychopathic state compulsive ideas and com- 
pulsive fears form the predominant symptom. The in- 
tellect is not only undisturbed, but may be unusually 
good. The patients exhibit throughout a pronounced 
feeling of mental illness , and frequently a clear insight 
into the morbidity of the individual symptoms. Evidences 
of a psychopathic condition may have existed from in- 
fancy, sometimes appearing as hysterical symptoms, and 
at others in the form of a congenital neurasthenia. 

First of all there appear simple compulsive ideas which 
force themselves upon the patients against their will, and 
in this way influence the freedom of the train of thought. 
Sometimes the content of the compulsive idea is purely 
indifferent, or at least not irritating. It is only the fre- 
quent repetition of the idea that causes annoyance. A 
physician was in this way tormented with the thoughts 
of death. Sometimes the idea is accompanied by a 
mental picture. One man was constantly seeing the hands 
of ghosts of whom he had once read. 

Odors and melodies can similarly haunt the patients. 
Such ideas are especially annoying when they are nasty 
or create horror. Some patients are compelled to con- 
template the sexual organs of those about them, even 
picturing them to themselves. Others when at stool have 
to dwell upon all sorts of disgusting scenes, or feel as if 
they were being shamed. 

In a second group of cases there is a compulsion to 
ponder over certain definite things ; for example, the 



names of persons (onomatomania), 1 and particularly names 
hard to remember. If unable to recollect a name casually 
heard or seen, the patients immediately strain every nerve 
to get it, think of it all day long, lying awake nights try- 
ing to recall it, and the tension cannot be relieved until it 
comes to them. Incidents of this sort occur even in nor- 
mal individuals. Some patients feel compelled to inquire 
the names of people whom they meet on the street ; others 
feel that they must form a definite picture of the face, 
form, or color of the hair of strangers. 

Another prominent tendency is to dwell on figures 
(arithmomania), when one is compelled to busy himself 
with the number of his house, the street, or of his room in 
the hotel ; or he counts compulsively the guests about the 
table, the number of forks, knives, and glasses, the number 
of designs in the carpet or wall paper. 

Frequently the compulsive ideas take the form of ques- 
tions which may be of a metaphysical nature, as, " Who is 
God?" "Where did he come from?" "How was the 
universe created ? " etc. Sometimes these questions refer 
to objects in the surroundings, when the patients are 
bothered with such questions as, " Why does that chair 
stand so and not so ? " " Why does it have four legs and 
no more or less ? " " Why is that house painted green and 
not brown?" etc. This, by Griesinger, 2 has been called 
" Gruebelsucht." 

The so-called "phobias," the anxious conditions, also 
belong here ; mysophobia (fear of dirt), agoraphobia (fear 
of public places), nyktophobia (fear of darkness), etc. The 
patients have these fears in spite of the fact that they 
know no harm can come to them. When subjected to 

1 Magnan, Psychiatrische Vorlesungen, 1893. 

2 Griesinger, Archiv f. Psy. I, S. 626, Berger, ibid. VI, S. 217. 


them, they may suffer from palpitation of the heart, be- 
come pale, tremble, have a cold sweat, nausea, faintness, 
polyuria, weakness of the legs, and finally may even lose 
control of themselves and collapse. The best known of 
these conditions is agoraphobia, 1 when the patients are in 
fear of public places. Some are unable to walk down a 
long, broad street, or in a place where they are alone. 
When they attempt this, they are so overcome that they 
cannot proceed. When the condition is extreme, they are 
afraid to go out on the street at all, some even remaining 
in bed. Closely related to this is the fear of height which 
prevents patients from standing near a railing, on the 
brink of a precipice, going over bridges, or of being in a 
theatre. Among other morbid fears might be mentioned 
that of being alone in the dark, riding on trains, and going 
through tunnels. These patients find no pleasure in travel- 
ling, do not enjoy going to church or the theatre, and al- 
ways sit near the door, ready to fly at the first sign of 

There is also a condition called erythrophobia, in which 
patients fear blushing. When any one enters the room or 
their name is spoken they immediately blush, which causes 
great discomfort for fear that they may be thought guilty 
of some misdeed. It may even create so much annoyance 
that they are compelled to give up business. There is 
also the fear of wearing new clothing because of the new- 
ness and accompanying physical discomforts. The pro- 
nounced superstitions exhibited by many are allied to 
these fears. Some patients have fear of impending illness 
or some chronic disease. 

Among the numerous phobias another is the fear of dirt 
contagion or infection (mysophobia). The countless bac- 

1 Westphal, Archiv f. Psy. Ill, s. 130 ; Cordes, ibid. Ill, s. 521 ; X, s. 48. 


teria always present in the air are one of the chief sources 
of annoyance. The patients are everywhere complain- 
ing of the bad air and throwing up windows; they are 
afraid of handling brass or copper, or are always taking 
things up by nails or pieces of glass. They notice in their 
food a shining bit which may possibly be a pin. Books, 
especially, are avoided as a possible source of contagion. 
Occasionally a patient has the fear of destroying some- 
thing of value. One lady was always in fear of throwing 
some important letter into the fire, or destroying it, and 
for this reason carefully avoided touching any paper and 
finally even printed books. 

The patients are constantly washing themselves, and 
are fearful of disease from touching money, books, or 
papers. In taking food they have to wipe the dishes fre- 
quently, and inspect carefully every bit of food. Then 
there are those cases where the patients are not in so 
much fear for themselves as they are for others. They 
are constantly in fear that they may not have made 
themselves understood. After leaving a friend they sit 
down and write a letter in order to be sure that they are 
understood, but the letter is barely off before they are in 
doubt as to whether they made themselves clear in it. 
These patients weigh every word before they express 
themselves, trying to avoid false interpretations. In 
many cases the fears are quite silly in spite of better 
judgment; they feel that they are guilty of crime, of 
homicide, have committed a theft, or have poisoned a 
relative. In the lighter forms these doubts exist only in 
one field of activity ; in the severer forms they influence 
all the actions of the patients. Perhaps it would have 
been better if they had not drunk that glass of water, or 
they possibly have harmed themselves by taking that 



piece of cake. Had they not gone out of doors, it would 
have been better ; an accident would not have happened 
or that fire would not have broken out. It is actually 
impossible for them to remain at rest, because of the un- 
certainty as to whether they have closed a door, or have 
sealed a letter that they have mailed. Consequently, 
there arises an ever increasing painstaking in all the little 
details of daily life. They are always turning back to 
see if they have locked the door, or tearing open letters 
to see if they have enclosed the right one. 

As the result of fear of misplacing something or of soil- 
ing themselves there develops the fear of contact, " delire 
du toucher " of the French. All the needles in the house 
are thrown away and they give up sewing for fear that 
they may injure themselves. The windows are no longer 
washed, because the glass might break and cut them. 
They no longer offer to shake hands, but wear gloves and 
open windows with their elbows. They begin the habit 
of washing, not only their hands, their bodies, but also all 
of their clothing. Some patients spend the entire day in 
dressing, undressing, and washing themselves and their 

The consciousness of all these patients is entirely clear. 
They have an insight into their condition, and a desire, 
but not the strength, to free themselves from it. They 
know well enough that no real harm threatens them, but 
that they are overwhelmed only by the " fear of the fear." 
Their emotional attitude shows anxiety, which often is in 
marked contrast to their courage in real danger. They 
are usually of a weak, dependent nature. In their be- 
havior and actions they frequently show nothing abnormal, 
and control themselves perfectly before strangers. 

A common characteristic of almost all phobias are the 


crises. As soon as one threatens to do that feared by the 
patient, or to hinder him from carrying out his usual 
means of protection, he develops an anxious condition 
with excitement. It is quite astonishing to see how the 
patients, until now hoping for relief of the disease, sud- 
denly turn about and oppose any real attempt at combat- 
ing it. There are other patients whose compulsive fears 
seem to take the form of impulses, when such questions 
as the following keep arising : " What would happen if 
you should undertake to do this or that : if you should 
kill some one with that knife lying there, or set that 
building on fire, or shout aloud in church ? " For this 
reason they avoid the use of sharp instruments and never 
handle matches, etc. 

The course of the disease varies much. Complete dis- 
appearance of the symptoms seldom occurs, and then only 
for a short time. Rapid improvement is often noticed. 
It appears usually during the period of development. The 
first symptoms often follow some shock. The prognosis is. 

Treatment. — In youth careful attention to the demands' 
of physical development is necessary. Threatening pecul- 
iarities should be warded off by careful training and all 
deleterious influences removed, which tend to weaken the 
physical and mental powers of resistance. The symptoms 
of the disease can be combated by persistent and patient 
training with a view to strengthening and encouraging 
the patient to struggle step by step against the morbid 
compulsion. The significance of their condition should 
always be made clear to the patients, and they must be 
impressed with the fact that they will overcome it more 
by abstraction and diversion than by exercise of will 



Westphal, Archiv f. Psy., VIII, S. 737. 

Kaan, Der neurasthenische Angstaffect bei zwangsvorstellung und 
der primordiale Gruebelzwang, 1893. 


Impulsive insanity is characterized by the development 
of morbid tendencies and impulses which may continu- 
ously predominate over volition or appear only in par- 
oxysms. These acts, which appear without motive, are 
performed because of an irresistible impulse. The im- 
pulses do not arise as the result of a conscious plan, but 
appear suddenly, are quickly executed, and often quite 
indistinct, thereby causing the actions to appear unpre- 
meditated, purposeless, and even absurd. 

A transition state from normal impulses to impulsive 
insanity may be seen in those individuals in whom such 
impulses are quite trifling and indifferent, appear and dis- 
appear rapidly, perhaps only under unusual circumstances, 
and lead to very simple deeds. Maudsley tells of a 
man who for weeks was annoyed by an impulse to 
overturn two stones which lay upon a wall, finally 
forcing him to sneak out at night in order to perform 
the absurd act. But the disease becomes of great im- 
portance to the patient, for whom the impulses are 
constantly involving the environment and interfering 
with comfort and occupation. 

In some cases the morbid impulses are all in one 
direction. Of these the most important is the impulse 
to set fire (pyromania), which is exhibited especially 
by young females, most often during puberty. Some- 
times the morbid pleasure of seeing things burn, and at 
hearing the crackle, dates from early childhood. Another 
common form of impulse of this kind is seen in the 



tendency to skilful but foolish stealing (kleptomania), 
encountered almost exclusively among women, and es- 
pecially during menstruation and pregnancy. The stolen 
articles are frequently almost or quite worthless for the 
patients. In some cases there is a desire for some one 
definite thing, which is accumulated in great quantities. 
Sexual impulses may accompany this condition. Further 
expressions of degeneracy of normal impulses are seen 
in the silly fondness for animals, the irresistible tendency 
to play, marked increase of sexual impulses, and many 
similar digressions. 

The morbid impulses to destroy and kill are other 
instances. There is a special group of young women who 
show a morbid impulse to beat little children entrusted 
to their care. Here there exists a close relationship to 
those sexual impulses which have been called sadism, 
masochism, and fetichism. The men who prod women, 
who snip hair, slash ladies' dresses, steal women's shoes 
or linen, and many exhibitionists belong to this class. 

The mental endowment of these patients usually shows 
no marked defect, but in some severe cases there is a more 
or less high grade of mental weakness. In the mental 
field there is apt to exist some weakness, and the patients 
may be childish, shy, or seclusive. 

The symptoms of the disease appear only during cer- 
tain periods of life, and particularly during the period of 
development, at which time there is a condition of lessened 
resistance in both the physical and mental fields. In 
some cases there is improvement with development, and 
the formation of a stable personality. Only occasionally 
is periodicity noticed. One should not confound the' 
irrevocable relapsing of the criminal with the regular 
repetition of similar criminal acts in these patients. The 


criminal sets fire, kills, and steals, but he does it from 
selfish motives, and for some definite purpose, perhaps to 
do some one injury, and the dominating impulse forces the 
individual to the deed against his will. Frequently he 
has a feeling that the action is inconsistent, unnatural, 
and morbid. On the other hand, impulsive insanity 
approaches very closely some forms of compulsive insanity. 
These patients do not confine themselves to deeds close 
at hand ; they often have an abhorrence of them and 
fear that they may yield to something which really does 
not exist. Here there is apt to be associated with the 
idea of the morbid act a feeling of desire and eagerness for 
the performance, and they cannot remain quiet until it 
is done. The act is immediately followed by a feeling 
of relief, but failure brings disappointment at the result. 
There is not a trace of penitence, except where there 
is some moral defect, and especially when, after the excite- 
ment of the deed, those opposing ideas appear which 
have been forced to the background by the overwhelming 
desire. For this reason, it is clear that we have on the 
one hand to do with real morbid impulses, and on the 
other with simple compulsive fears. The two important 
characteristics of impulsive insanity are that there is no 
clear and rational purpose for the deed, and that there 
are evident defects in other fields of the psychical life. 

The treatment of impulsive insanity naturally lies in 
the education of the patient, which must be adapted to 
individual cases and carefully conducted with proper regard 
for the physical development. It is of greatest impor- 
tance that the patients do not become addicted to the 
use of alcohol. There are some cases, who, for the protec- 
tion of society, need to be confined in an institution. 
Here they can be educated to lead a useful life. 


This psychopathic state, which received its name from 
Westphal, refers to those sexual propensities appearing 
mostly in youth, exhibited by individuals of the same sex 
for each other, with an indifference or even an abhorrence 
of the opposite sex. The condition has also been well 
described by Krafft-Ebing, Moll, and Schrenk-Notzing. 

Etiology. — The contrary sexual instincts are far more 
prevalent among men. It is an uncommon condition, the 
cases reported to date numbering but a few hundred, 
although homosexual patients maintain that it is by 
no means rare. Ulrichs, in his own morbid experience, 
claims to have encountered two hundred cases. It is 
more prevalent in certain employments, such as among 
decorators, waiters, ladies' tailors ; also among theatrical 
people. Moll claims that women comedians are regularly 

The condition develops from a state of degeneracy. It 
is a view of Krafft-Ebing, emphasized by the statements 
of the patients themselves, that the peculiar perversion of 
the sexual impulse is congenital. Schrenk-Notzing, on 
the other hand, lays some stress upon accidental factors, 
which happen to exert an influence upon the sexual feel- 
ings long before the age of sexual development, such as 
the intercourse of naked boys while bathing, wrestling, etc. 
Sometimes passionate friendships exist among young chil- 
dren who are still ignorant of the sexual differences. But 
it is only with the abnormal child that such accidental 



influences upon the early sensual feelings can have any 
power in the later development of the sexual impulses. It 
seems most probable, then, that the morbidity of the con- 
dition depends not upon impulses which are perverted 
from the onset, but upon a characteristic tendency, origi- 
nating in a hereditary state of degeneracy. 

Symptomatology. — Sexual impulses develop early, and 
usually to a marked degree, sometimes leading to onanism. 
The natural heterosexual impulses may have developed 
first, being displaced later by stronger morbid tenden- 
cies. The patients, both in the waking and dream 
states, experience pleasurable sexual feelings only in con- 
nection with their own sex. Attempts at natural sexual 
intercourse are unsuccessful, or accomplished only with 
difficulty. Close associations are usually formed with 
some individuals of the same sex, which usually develop 
into passionate friendship with extravagant display of 
affection, letter-writing, sending gifts and flowers, and 
exhibitions of jealousy. This frequently extends to kiss- 
ing, embracing, and occasionally to masturbation and 
other forms of sexual perversion, but rarely to pederasty. 
In these friendships the physical and mental superiority 
of one individual over another may aid in arousing the 
sexual feelings. Usually both individuals are homosexual, 
but sometimes the patient desires intercourse only with a 
normal individual. Frequent changes of the affection, 
with disruption of these friendships, often occur, showing 
the fickleness of the patients, though in some cases such 
relationships are maintained for years. Differences in 
social rank is of less importance than in normal individ- 
uals. A few patients of the better classes are attracted 
by mechanics, and especially by soldiers. 

The patients usually remain unmarried. Those who do 


marry, either in the hope of overcoming their perverse 
tendencies or from the desire to have children, are usually 
true to their marital duties, except in the matter of sexual 
intercourse. Some indulge occasionally, but more, regu- 
larly, in homosexual intercourse. 

Other symptoms indicative of a morbid constitutional 
basis are usually present, especially the physical stigmata. 
Judgment is usually unimpaired, as well as the ability to 
comprehend, but there is an increased sense of fatigue, 
lack of perseverance with mental work, and a tendency to 
dream. Imagination is prominent and interferes with the 
capacity for purely rational activity. Some are especially 
endowed in an artistic way, being good musicians and 
artists ; but they also possess a keen sense of appreciation 
of their abilities. Mental weakness may exist. Many 
patients have an insight into the morbidness of their 
impulses, and defend themselves on the ground that the 
impulses are the natural and involuntary product of their 
constitution. In the emotional life they present irritability, 
are sensitive, moody, and impressionable, often timid, and 
given to passionate outbursts of feeling. In actions they 
appear effeminate, vain, pliable, unstable, and are some- 
times sluggish. They are often careless about their work, 
easily distractible, and untrustworthy. The sexual im- 
pulses are apt to gain control over them, causing neglect 
of business. Fetichism and other perversities may also be 

The condition of psychic hermaphroditism is occa- 
sionally present, when sexual feelings are exhibited 
toward both sexes, though usually stronger toward one 
sex than the other. Where homosexuality is very pro- 
nounced, the individual may experience a change of per- 
sonality, a man becoming feminine in manner, gait, and 


countenance. He becomes affected in manner, vain, co- 
quettish, takes great pains with his personal appearance, 
desires to be in fashion, wears flowers, and uses cosmetics. 
Some develop a fondness for women's employment, do 
needlework, arrange their rooms after the fashion of a 
woman's boudoir, and they may even dress in women's 
clothes, padding the hips and breast, talk in a falsetto 
voice, and in every possible way simulate feminine traits. 
Early evidences of such traits may make their appearance 
in childhood. A few patients present physical character- 
istics indicative of the opposite sex ; men are beardless, 
possess high-pitched, light voices, have soft white skin, 
with a more marked pannicus adiposus and well-developed 
mammae ; while the homosexual females have a deep, 
coarse voice and show a tendency to grow beards. The 
former are called by Krafft-Ebing androgyny, and the 
latter gynandry. Hermaphroditism has never been en- 
countered in homosexual individuals. 

The course of the disease, which usually reaches its full 
development between twenty-five to thirty-five years of 
age, is always prolonged. In the acquired homosexuality 
there is often a long struggle before the patient becomes 
a confirmed pervert. The homosexual tendencies may 
appear periodically with or without accompanying states 
of general excitement. 

Diagnosis. — It is not a difficult matter to identify 
homosexual patients where there has been a marked 
transposition of the traits characteristic of the sexes. 
Yet normal sexual instincts may exist in spite of such a 
transposition. Usually the condition becomes known to 
the physician only through the communication of the 
patient. It is necessary to distinguish between contrary 
sexual instincts and mere practice of homosexual acts, 


the latter being pure perversity, as practised among 
prisoners, etc., who return to normal sexual relations 
upon gaining freedom. 

The prognosis is more favorable than is usually thought. 
Very many cases improve and some even recover under 
the influence of treatment. 

Treatment. — The most successful method of treat- 
ment is through the use of hypnotic suggestion. This 
is directed first against the increased sexual excitability 
and masturbation, which is frequently present ; next it is 
applied to the insensibility of the patient toward his own 
sex, and finally in creating an excitability toward the 
opposite sex and a tendency to heterosexual intercourse. 
The hypnotic influence over the patient, dealing as it does 
with a deeply rooted habit, is acquired slowly and with 
difficulty. Schrenk-Notzing lays great stress upon regular 
natural intercourse, but excessive coitus must be avoided, 
because it may have an injurious effect upon the self- 
confidence. Treatment directed at the general nervous 
condition is also of importance, and should include the 
establishment of a routine in the physical and mental 
life, with attention to the diet, exercise, and relaxation. 
One should remember that even though marked improve- 
ment or recovery takes place, the original defective basis 
still remains. 


Westphal, Archiv f. Psy., II, 1. 

v. Krafft-Ebing, Psychopathia Sexualis, 1900. 
Moll, Die contraere Sexualempfiodung, 1891. 

Schrenk-Notzing, Die Suggestionstherapie bei krankhaften Erschei- 
nungen des Gerschlectssinnes, 1892. 


Undek this heading are described those mental states 
which are the result of an incomplete or early interrupted 
development of mental life. In distinction from the pro- 
cess of mental deterioration these states may be regarded 
as conditions of retarded mental development. These 
conditions, however, may be closely associated with each 
other, as when a deterioration psychosis appears in indi- 
viduals with defective development, when either the per- 
version or the deterioration may be the more prominent. 

A defective hereditary endowment is almost always 
present. The pathological basis for defective mental 
development is the incomplete development of the cerebral 
cortex. This is often due to some disease occurring during 
fetal or infantile life which has an injurious influence 
upon the developing nervous elements. Our knowledge 
of the anatomical facts is as yet so incomplete that it is 
impossible, on a pathological basis, to differentiate be- 
tween the different grades of defective mental develop- 
ment. In a general way the lighter forms are designated 
imbecility ; and the severer, idiocy. 


This form of defective mental development is character- 
ized by a moderate degree of mental incapacity, which is 
usually of equal prominence on all sides of the mental life ; 
it may, however, involve chiefly the moral field, when it 
is sometimes called moral imbecility. Clinically, imbeciles 



may be divided into two groups, the stupid and the 
active, according to the degree of mental activity. 

The fundamental symptoms in the stupid form are stu- 
pidity and insensibility. There is an inability to receive 
many impressions, or to grasp and utilize the experiences 
of life ; consequently the knowledge of the outside world 
confines itself to the immediate surroundings, while events 
without their narrow mental horizon pass unnoticed. 
Probably the sensory presentations are retained, but there 
is an absence of a unification of single experiences into 
general ideas. Individual and insignificant elements make 
up the fund of experience. There is no comprehensive 
elaboration of experience, and general relations are appre- 
hended without the establishment of any definite points 
of view. Essential and fundamental relations and dis- 
tinctions are not recognized. Thought is scanty, limited 
mostly to daily experiences, usually travels the same path, 
and, according to the research of Buccola, is really retarded. 

Judgment is defective and uncertain and often deter- 
mined by chance ideas not the outcome of past experience. 
Patients also fail to consider the possible consequences of 
their actions, either in reference to themselves or others. 
Memory is accurate only for the most prominent events of 
life. Yet sometimes trifling incidents are firmly retained, 
while the more essential are forgotten. The narration of 
events as remembered by them is noticeably faulty because 
of numerous omissions and changes. The same narrations 
at different times show many contradictions, though some- 
times they are repeated word for word. Consciousness 
is unclouded. The patients recognize the surroundings 
and comprehend questions. They have no insight into 
their mental condition, but usually regard themselves as 
perfectly sound. 


It is quite in accord with these mental characteristics 
that in the actions and conversation of patients their own 
personality should always come into prominence. The 
narrower one's experience, the more prominent is the role 
of the Ego, leading in the case of the imbecile to more or 
less marked selfishness. The central point about which 
the whole life revolves is their own physical well-being, — 
eating and drinking and the possession of things desired, — 
while all else is indifferent. Occasionally they fail to show 
the natural affection for parents and relatives. The super- 
ficial sorrow at the loss of some relative is quickly lost in 
the pomp of the funeral procession and the joy over a new 
suit of mourning. The absence of sympathy for those 
who are in want and unfortunate may explain the cruelty 
which they sometimes display toward animals and in their 
combats with others. 

Lighter grades of this type of imbecility often fail of 
recognition because of the absence of sharp border lines 
between them and the stupidity sometimes present in 
normal individuals. Imbecilic defects, however, become 
more and more apparent as the individual advances in 
age and is compelled to take up some responsibility in 
life. Yet these defects may not be recognized because 
of the patient's ability to utilize a certain amount of expe- 
rience and to engage regularly and with some mechanical 
skill in a simple occupation. But just as soon as anything 
extraordinary occurs, a mental shock or a temptation, 
which demands discretion and decision of action, the 
mental and moral incapacity becomes evident. Unfortu- 
nately at this time their actions are judged from a legal 
and not from a medical standpoint. Rigid military disci- 
pline brings to the light many such cases, especially in 
those countries where military service is required. It 


becomes most apparent in stubbornness, insubordination, 
desertion, and attacks upon officers. Lack of judgment 
in handling these cases sometimes results in suicidal 

Imbecility is usually recognized at an early date. In 
infancy it may be noticed that patients are tardy in learn- 
ing how to laugh, to imitate, and to speak. Later, at 
school, they are backward in studies, are sluggish, indolent, 
show poverty of thought and inability to comprehend, and 
soon become the sport of their playmates. They find diffi- 
culty in learning to read, write, and reckon, and the few 
facts in geography or grammar, committed to memory, are 
soon forgotten, since they are not essential to their limited 
experiences of life. A fairly good memory may conceal 
their incapacity for a long time. 

The patients are very often refractory, hard to train, 
and have a tendency to develop bad traits, such as steal- 
ing, annoying dumb animals, and indulging in sexual 
improprieties, which often necessitates their commitment 
to industrial schools. During youth and puberty their 
mental incapacity becomes still more evident, because of 
the marked contrast to the rapid mental development of 
their playmates. At this time their own development 
comes to a standstill or may even retrograde, presenting 
resemblances to the progressive deterioration of dementia 

In the active or energetic type of imbecility, there is a 
morbid activity of the attention and imagination, in con- 
trast to the general sluggishness of the stupid form. Pa- 
tients are attracted by every new impression, and unable 
to direct their attention permanently to any one object; 
hence their observations are hasty and superficial. They 
are always ready to pass judgment without deliberation. 


This susceptibility to new and accidental impressions ren- 
ders their view of the outside world very incomplete and 
fragmentary. Such vague pictures lead to faulty concep- 
tions and form the basis for incorrect judgment. As soon 
as ideation leaves the purely sensory field, the logical train 
of thought yields to the influence of the lively imagination, 
while the sharp definition characteristic of general ideas 
disappears. Circumstances existing only in their imagi- 
nation are of far more importance in their deliberations 
than absolute facts. Thought, therefore, becomes unsteady 
and shows many inconsistencies ; patients vacillate in their 
plans from day to day, draw inconsistent conclusions from 
the same premises, and thus their views of life and the 
outer world lack reality. 

Their flighty conversation contains a frequent repetition 
of certain high sounding remarks and commonplaces, which 
often have little bearing upon the sense. They are very apt 
to lose the thread of conversation, refer to the most diverse 
subjects, but usually finish with some very striking remark. 
Such a bombastic style very often conceals from the inex- 
perienced the actual mental enf eeblement, and leads to their 
being regarded as unusually bright individuals. It is quite 
in accord with these mental peculiarities that patients not 
only embellish and distort their recollections with many 
fanciful ideas but also fabricate extensively. In spite of 
evident contradictions in their statements, they reassert 
them tenaciously, and refuse further discussion. Accusa- 
tions of the patients against relatives and fellow-patients 
should, therefore, be accepted with the greatest caution. 
These energetic patients possess a better memory than the 
apathetic, are able to acquire some new knowledge, and to 
adapt themselves to new environment to a certain extent. 

The emotional attitude presents a mobility equal to that 



encountered in the attention and the imagination. Every 
impression is accompanied by an accentuated but rapidly 
vanishing tone of feeling, and the moods vacillate from 
one extreme to another, showing despondency and exuber- 
ance, despair and enthusiasm, which appear upon little 
provocation. Violent likes and dislikes change from day 
to day ; the dearest blessed doctor of to-day becomes the 
vilest scoundrel to-morrow. While extravagant in their 
emotional expressions, with a tendency to emotional 
outbursts, they are readily diverted and pacified. Irri- 
tability and sensitiveness are always present to a greater 
or less degree, especially when patients believe themselves 
interfered with ; often they are docile and good-natured. 
An exaggerated feeling of self-importance regularly accom- 
panies this form, some patients even believing themselves 
specially endowed and often boasting of their prospects, 
while at the same time showing a lack of insight into 
their diseased condition. Any shortcomings on their part 
are explained by the hostility of relatives or lack of 

In conduct the patients are odd, freakish, sometimes 
loquacious, forward, pretentious, and silly ; sometimes quiet, 
docile, and reticent. They are apt to dress in a peculiar 
manner or to be slovenly in appearance. They work with 
varying zeal. In youth they are frequently considered bright, 
especially by the parents, but later become fickle, unable 
to employ themselves at all, leave home, wander aimlessly 
about, drink, and indulge in all sorts of excesses. Many 
prostitutes belong to this class. In many of these cases, 
where there seems to be only a light grade of imbecility, 
there may be some question whether we are not really 
dealing with conditions of degeneracy, but the presence of 
profound mental deficiency, in spite of a certain amount of 


superficial activity, should leave no doubt. Chidden desig- 
nated such patients as " high-grade imbeciles." 

Imbecility may form the basis for the development of 
other psychoses ; as manic-depressive insanity, the psy- 
choses of involution and dementia praecox, the last of 
which in seven per cent, of cases appears on an imbecile 
basis ; besides this, very often only individual symptoms of 
other psychoses appear, such as periods of excitement and 
depression, not of the manic-depressive type, single transi- 
tory expansive or persecutory delusions, rarely hallucina- 
tions, and especially those attacks so characteristic of the 
constitutional psychopathic states. As sighs of physical 
degeneration we frequently find stigmata ; as, anomalies 
of the skull, malformation of the palate, misshapen ears, 
puerile expression, chorea, etc. 

Moral imbecility represents another form of congenital 
mental weakness, which includes chiefly the realm of the 
feelings. It is characterized by the absence or weakness 
of those feelings which inhibit the development of marked 
selfishness. The intellect as regards matters of practical 
life is moderately developed ; patients apprehend well, are 
able to accumulate more or less knowledge which they 
utilize for their own advantage, possess a good memory, 
and show no defects in the process of thought. They do, 
however, lack the ability to obtain general view points, 
to perform any mental work of a high grade, and to form 
an adequate conception of life or the outer world. 

Morally, their lack of sympathy is manifested from 
youth up in their cruelty toward animals, the tendency to 
tease and use roughly playmates, and an inaccessibility 
to moral influences. From this they develop the most 
pronounced selfishness, lack of sense of honor, and of 
affection for parents and relatives. It is impossible to 


train them because of the absence of love and ambition. 
They tell falsehoods, become crafty, deceitful, and stub- 
born. The egotism becomes more and more evident in 
their great conceit, bragging, and wilfulness, their inor- 
dinate desire for enjoyment, their indolence and dissipa- 
tion. They are incapable of resisting temptation, and 
give way to sudden impulses and emotional outbursts, 
while the susceptibility to alcohol is especially prominent. 

Very many professional criminals present the symptoms 
of moral imbecility to a marked degree. In these cases 
there is no doubt but that a scanty and defective training 
and education under circumstances unfavorable to a healthy 
moral development are of equal importance with the de- 
fective heredity, which is a constant factor. Indeed, there 
is often an extraordinary persistency of the criminal ten- 
dencies in these individuals, who can in no way be 
diverted from this profession. The development of spe- 
cialties among these criminals is another expression of a 
one-sidedness of conduct. 

Course. — The course of imbecility varies considerably ; 
some patients, unsuccessful in their attempts to enter a 
profession or to become employed in mechanical arts, 
engage in simple labor, and failing in this, they become 
a burden to the family. It is not infrequent for them to 
develop some psychosis later in life, especially manic- 
depressive insanity and senile dementia. Others show 
irregular periods of excitement, with aggressiveness, great 
irritability, and variable emotional moods. Usually it 
becomes necessary at some time during their life to con- 
fine them in almshouses or hospitals for the insane. 

Diagnosis. — There are some cases of dementia prcecox 
which are difficult to differentiate from the lighter, active 
forms of imbecility. The character of the onset, dating 


from childhood, the absence of hallucinations and pro- 
nounced delusions, and of any evidence of earlier acquired 
knowledge, except as much as might be consistent with 
the present productiveness of the patient, speak for 
imbecility. Furthermore, in dementia praecox patients 
may show some improvement, while imbeciles present no 

There are a few cases of hysteria with a moderate 
degree of deterioration which might be confounded with 
imbecility, but in them the course of the disease is not as 
uniform and the mental weakness is not as evident on all 
sides of the psychical life ; while in imbecility but few 
patients present hysterical symptoms. There are all pos- 
sible transition stages between imbecility and the normal 
state, among which should be classed those weak-minded 
individuals who are over-credulous and superficial in 
knowledge, getting a smattering of everything but know- 
ing nothing thoroughly; who take hold of everything 
new with enthusiasm, are easily led astray and indulge 
in excesses, and who are always in doubt as to their real 
motives for action. 

Treatment. — The treatment of congenital imbecility con- 
sists principally in providing an appropriate education, with 
a view to developing any capacity that may exist. This is 
best accomplished in the hands of some competent tutor 
or in a private or state institution established for that 
purpose. The training should by no means be directed 
simply toward mental education, but should include man- 
ual training. The use of alcohol should be strenuously 
avoided. If, in spite of training, the patients develop 
dangerous tendencies, hospital care is necessary. 


Idiocy is characterized by a more profound degree of 
mental incapacity than imbecility. 

Etiology. — Defective heredity is one of the most impor- 
tant etiological factors. Idiocy may be regarded as the 
final stage of hereditary degeneration. Wildermuth finds 
defective heredity in seventy per cent, of cases, mostly in 
the form of alcoholism in the parents. Possibly also 
intoxication of one or both parents at the time of copula- 
tion predisposes to idiocy. Severe illness or mental shock 
during pregnancy and hereditary tendency to tuberculosis 
(Piper) have been noted as causes. Injuries at the time 
of birth, prolonged asphyxia, but especially compression 
by narrow pelves or forceps are probably important factors. 
In idiocy developing after birth (one-fourth to one-third of 
cases) the most important causes are infectious diseases, — 
typhoid fever, measles, scarlet fever, and diphtheria ; also 
head injuries, congenital syphilis, and rachitis. 

Premature ossification of the cranial sutures is no longer 
regarded as a cause of idiocy, but rather as an accompani- 
ment, recent investigation showing that the growth of the 
calvarium is determined by the proportional growth of 
the brain and not vice versa. Malformation of the cra- 
nium occurs in at least one-half of the cases, in which 
anomaly macrocephaly is far more prominent than micro- 
cephaly. An extreme grade of the former of these condi- 
tions is represented by Plate 9, while Plate 10 represents 
the condition of microcephaly. Furthermore, the closure 
of the suture has nothing to do with the malformation 


Plate 9. Macrocephaly. 


of the brain. Narrowness of the base of the cranium 
accompanies more often the profoundly stupid forms of 
idiocy, and smallness of the vertex, the excited forms. 
More than one-half of idiots are first-born, and four to 
five per cent, are twins. The male sex predominates. 

Pathological Anatomy. — Many cases present defective 
development of the central nervous system, either smallness 
or increased size of the entire encephalon or malformation 
of some of its parts ; absence of corpus callosum, of cere- 
bellum, inequality of hemispheres, sparsity or anomalies of 
convolutions and microgyri, conditions which represent 
halting of development, or even a reversion to structures 
characteristic of lower animals. In some cases evidences 
of genuine disease processes are found ; encephalitis, menin- 
gitis, hydrocephaly, and tumor formation, causing exten- 
sive destruction of the cortex (porencephaly) or a general 
atrophy. Similar conditions may be due to vascular 
changes, of which the most important are endarteritis, 
thrombosis, and embolism ; also occlusion of vessels caused 
by traumatic hemorrhage at the time of birth or later. 

Microscopically, we may find either an insufficient devel- 
opment of the neurones or evidences of former disease 
processes. In under-development the nerve cells do not 
develop beyond an embryonic stage (Hammarberg). The 
cortex is barely half its normal thickness, the whole number 
of cells is reduced, while they stand closer together, in regu- 
lar rows, with a marked diminution in the amount of gray 
matter between them, so that the different layers cannot 
be clearly distinguished (a characteristic of lower animals). 
The cells themselves are embryonic in structure, being 
mostly of the same size and globular in form. This faulty 
development may vary in different parts of the cortex. 
See Figure 1, Plate 4. 


In other cases there may be normal development, with 
the usual number and arrangement of cells, but there are 
areas in which the cells have entirely disappeared as the 
result of a disease process, presenting also an increase 
of glia. In the few cases of hypertrophic sclerosis, the in- 
crease in the size of the brain is due to the great increase 
of glia, either as an accompaniment or as a result of a de- 
generative process in the cortex. The nature of the causes 
which produce such lesions in fetal and early life is still 
unknown. They may be due to intoxication or infection. 

Symptomatology. — The symptoms of the disease are 
best considered in two groups, the severe and the light 

In the most extreme cases of the disease, patients are 
unable to comprehend external impressions, to gather new 
experience, or become acquainted with the environment, 
are unable to form clear ideas or judgments, and indeed 
barely possess self-consciousness. The emotional life is 
confined to mere vacillations of the general feelings. 
Consequently, the impulses arising from these feelings 
lead only to simple actions, such as the taking of food. 
The patients eat anything placed before them, even to 
pieces of clothing and rubbish. Idiots are not excitable ; 
they show very little, if any, fear or pleasure, at the 
most, manifesting some pleasure in kicking or swaying 
movements, while hunger or physical pain may be ex- 
pressed in monotonous or shrill cries. If repeatedly 
pricked in the same place, causing them to cry out with 
pain, they do not try to protect themselves. Some even 
pound themselves severely, inflicting wounds, but imme- 
diately repeat the act. One girl would impulsively bite 
deeply into the flesh of her arm, unless prevented. 

Teething is delayed, and the whole physical develop- 

Plate 10. Microcephaly. 


ment retarded. The countenance is usually stupid and 
vacuous. The movements are clumsy and awkward; 
patients do not walk until late, and some never even 
learn to stand but are absolutely helpless. Some restless- 
ness may develop, with a tendency to move aimlessly 
about, to sway the head or body back and forth rhythmi- 
cally for a long time, to clap the hands, or to grunt. 
Convulsive attacks are of frequent occurrence. These 
patients are so utterly helpless that without constant 
attention they would quickly perish. 

In the light cases, it is possible to fix the attention 
momentarily by the aid of some striking object, but the 
patients themselves are quite unable to direct the atten- 
tion. A few clear sensory impressions may enter con- 
sciousness, and a limited number of ideas may be formed, 
which are extremely simple, always incomplete, and without 
connection. Memory is very poor, there is no ability to 
make a selection from different impressions in order to 
establish a basis for the formation of concepts, and, 
indeed, a psychic personality is never developed. Speech^ 
and therefore intercourse with the environment, is poorly 
developed. Unable to form sentences, idiots present a 
mixture of incomplete words or syllables similar to the 
early efforts of an infant. They do not imitate, play, or 
busy themselves, and are very susceptible to fatigue. 
Without thought or care for the future, they live indiffer- 
ently from day to day. 

The lower sensory or selfish feelings dominate the emo- 
tional attitude, and liberate only those impulses for action 
which gratify a momentary pleasure. Idiots never feel 
attracted toward any special individual, never express 
gratitude or show grief. When irritated by rough treat- 
ment or opposed, they may show sudden outbursts of 


rage, attempting to destroy something or to injure some 
one. Sexual desires may either remain undeveloped or 
appear early and lead to reckless masturbation and 
sexual assaults. Often the appetite for food is abnormally 
developed, patients eating ravenously and feeding them- 
selves with their hands. A few show some one-sided 
capabilities, such as a good memory for numbers or words, 
or some simple technical skill. Many idiots are fond 
of music. 

In the lighter grades of idiocy, two types may be dis- 
tinguished, the stupid or anergic, and the excited or active, 
depending upon the distractibility of the attention. The 
anergic patients are torpid, thought is sluggish and very 
limited, and there is pronounced emotional indifference. 
In the active (erethisch) patients, the attention wanders 
aimlessly, filling consciousness with a variegated, inco- 
herent jumble. The emotions change rapidly. At one 
time patients are stubborn ; at another, show purposeless 
activity, running about, laughing, crying and clapping 
the hands. Between these two groups there are numerous 
transition stages. 

In idiocy periods of excitement or depression may 
occur which present some similarity to attacks of manic- 
depressive insanity, and the excitement which occurs in 
the end stages of dementia prsecox. Compulsive ideas, 
morbid impulses, periods of anxiety, sometimes with 
suicidal tendencies, may appear, and occasionally there 
may be simple childish expansive or persecutory ideas. 

Physical Symptoms. — There is a stunting of the whole 
physical development; the stature is undersized or even 
dwarfish. Countenance is childish. Hair is often absent 
from the face and pubes. The genitals are undeveloped ; 
menstruation absent, late, or irregular. Teeth are late 

Plate 11. Casts of symmetrical and asymmetrical palates, the latter of which 
were taken from idiots and imbeciles. 


in developing and often faulty in arrangement, and the 
palate is usually asymmetrical. (See Plate 11, the 
lower four rows in which represent misshapen palates. 
These are to be compared with the normal palates seen 
in the top row.) The special senses, especially hearing, 
are blunted. In eighty per cent, of cases the so-called 
stigmata of degeneration are present (Wildermuth), viz. 
malformation of the eyes, ears, mouth, nose, and especially, 
the bones of the face. Other frequent symptoms are in- 
crease or loss of the reflexes ; incoordination of the lower 
extremities, and of the eye muscles, and difficulty of speech, 
with elision of the end syllables stuttering, halting, 
and faulty articulation of some or most of the consonants ; 
all idiots are awkward and often show associated move- 
ments; mirror-writing is found, especially among the 
girls. Evidences of focal cerebral lesions are mani- 
fested by hemiplegia, paresis, contractures, convulsions, 
choreic and athetoid movements, aphasia, and in thirty 
per cent, of the cases, especially in boys, epilepsy (Wilder- 

Diagnosis. — The recognition of the disease, which is 
difficult only in infancy and in very early childhood, 
depends upon the insensibility of the children to external 
influences. They do not manifest a feeling of hunger, 
even when lying upon the breast or at the approach of 
the mother, are not attentive, do not smile or cry, and 
may be continually restless ; many give evidence of some 
cerebral disturbance, as paralysis or hemiplegia. The 
limbs may remain in a fetal condition; they do not 
learn how to walk or talk, and are unable to understand 
speech. The distinction between the lighter degrees of 
idiocy and imbecility is often arbitrary. Patients who 
show some mental development, especially in memory 


but not in apprehension and judgment, are in general 
considered as imbeciles. 

Prognosis. — The prognosis is unfavorable. While idiots 
can never reach the rank of normal men, the question of 
how much they can develop is of great importance. In 
general it can be said that if their attention can be held 
for some time, and they give evidence of memory, i.e. 
recognize articles and resist what they have once ex- 
perienced as disagreeable and appear to understand speech, 
the prognosis is more favorable. The appearance of 
epilepsy in early childhood is very unfavorable. During 
puberty, idiots often lose what little knowledge they may 
have acquired, and some even present the hebephrenic 
or catatonic picture of dementia praecox. Their life is 
usually short, because of their lessened powers of resistance 
to intercurrent diseases. 

Treatment. — Temperance in parents should be en- 
couraged as in important prophylactic measure. The 
condition of faulty nutrition, which is frequently present, 
improves with the relief of insomnia, the prevention of 
masturbation, removal of sources of focal irritation and 
strict cleanliness. Epileptic attacks should be combated 
with bromids, atropin, or other suitable measures, with 
the hope of preventing profound deterioration. Crani- 
ectomy in some cases of microcephaly is an irrational pro- 
cedure and is fast disappearing from practice. 

Besides treatment of the physical condition, the patients 
should receive training in institutions for the feeble- 
minded. Idiots left to themselves or in a poor environ- 
ment, rapidly go to the bad. Harmless patients in the 
case of sisters or brothers may become threatening or 
aggressive and attempt sexual assaults. Such patients 
are somewhat susceptible to training. This, however r 


requires a greater sacrifice of kindliness and patience, 
and more experience than can be obtained in the ordinary 
home. An effort should first be made to teach them to 
walk and use their hands, also to employ their different 
senses, to direct their attention and to speak, followed 
by special instruction in the perception of objects, in 
distinguishing them, and in forming simple judgments. 
As a result of such training, many patients yearly 
leave institutions well enough trained to be of use in a 
limited field. They, however, continue to need some 
care and supervision throughout life, as their inability to 
get along in the world and to utilize knowledge stands 
in striking disproportion to knowledge taught them. 


Emminghaus, Die psychischen Stoerungen des Kindesalters. S. 
243 f. 

Sollier, Der Idiot und der Imbecille, 1891. 

Voisin, J., Idiotie, 1893. 

Piper, Zur Aetologie der Idiot, 1893. 

Hammarberg, Studien und Klinik und Pathologie der Idiote, 1895. 

Shuttleworth, Mentally deficient children, their treatment and train- 
ing, 1893. 

Bouneville, Assistance, traitment et education des enfants idiots et 
degeneres, 1894. 

Ireland, Mental Affections of Children, 1898. 


Abscess, cerebral, insanity following, 

Acquired neurasthenia, course, 101. 

diagnosis, 101. 

etiology, 96. 

prognosis, 102. 

symptomatology, 97. 

treatment, 102. 
Acts, compulsive, 65. 
Acute confusional insanity. (See 

Acute decubitus, 223. 
Agarophobia, 383. 
Agraphia, 222. 
Alcoholic delusional insanity, 126. 

course, 128. 

diagnosis, 128. 

etiology, 126. 

prognosis, 129. 

symptomatology, 126. 

treatment, 129, 131. 
Alcoholic epilepsy, 113. 
Alcoholic intoxication, acute, 107. 
Alcoholic paranoia, 111, 129. 
Alcoholic pseudoparesis, 131. 

course, 132. 

diagnosis, 132. 
Alcoholism, 107. 
Alternating insanity, 307. 
Amentia, course, 93. 

diagnosis, 94. 

etiology, 90. 

pathological anatomy, 90. 

prognosis, 94. 

symptomatology, 91. 

treatment, 95. 
Androgyny, 395. 
Anxious excitement, 60. 
Anxious tension, 50. 
Aphasia, 221. 
Apoplectic insanity, 257. 

Apoplectiform attacks, in paresis, 219. 

in senile dementia, 279. 
Apperception, 14. 
Apperceptive illusions, 8. 
Apprehension, disturbances of, 13. 

hallucinations, 7. 
Arithmomania, 383. 
Arterio-sclerotic insanity, 249. 
Ascending paresis, 222. 
Association of ideas. (See train of 

external, 23. 

internal, 23. 

predicative, 24. 
Attention, 15. 

Brain tumors, insanity following, 250. 

Catatonic excitement, 58. 
Catatonic stupor, 176. 
Catatonic writing, 182. 
Cell shrinkage, 209. 
Cephalalgia, 99. 
Cerea flexibilitas, 179. 
Cerebral abscess. (See abscess.) 
Chronic alcoholism, 110. 

etiology, 110. 

pathological anatomy, 110. 

symptomatology, 111. 
Circular insanity, 307. 
Circumstantiality, 27. 
Cocain delusional insanity, 143. 
Cocain intoxication, chronic, 142. 
Cocainism, 141. 

etiology, 141. 

prognosis, 145. 

symptomatology, 141. 

treatment, 145. 
Cold packs, 246. 
Collapse delirium, course, 87- 

diagnosis, 88. 




Collapse delirium (continued) — 

etiology, 85. 

pathological anatomy, 86. 

prognosis, 89. 

symptomatology, 86. 

treatment, 89. 
Coma vigil, 75. 
Compulsive fears, 49. 
Compulsive ideas, 25. 
Compulsive insanity, 382. 

course, 387. 

treatment, 387. 
Congenital neurasthenia, 378. 

treatment, 381. 
Consciousness, clouding of, 12. 
Constitutional psychopathic states, 378. 
Contrary sexual instincts, 392. 

diagnosis, 375. 

etiology, 392. 

prognosis, 396. 

symptomatology, 393. 

treatment, 396. 
Convulsions, epileptic, 337. 

hysterical, 361. 
Cretinism, 149. 

etiology, 149. 

pathological anatomy, 149. 

symptomatology, 149. 

treatment, 151. 
Crises in compulsive insanity, 387. 

Defective mental development, 397. 

etiology, 397. 
Delire de negation, 259. 
Delire du toucher, 386. 
Delirium, acute, 236. 

anxious, 342. 

conscious, 343. 
Delirium tremens, 115. 

course, 122. 

diagnosis, 123. 

etiology, 115. 

pathological anatomy, 116. 

prognosis, 124. 

symptomatology, 117. 

treatment, 124. 
Delusions, 35. 

changeable, 38. 

depressive, 39. 

expansive, 39. 

fantastic, 38, 40. 

Delusions (continued) — 

hypochondriacal, 41. 

nihilistic, 40. 

of jealousy in alcoholism, 129. 

of jealousy in cocainism, 143. 

of jealousy in presenile delusional 
insanity, 268. 

of persecutions, 40. 

of self-accusation, 39. 

persistent, 39. 

systematized, 39. 
Dementia paralytica, 203. 

agitated form, 234. 

course, 241. 

demented form, 225. 

depressed form, 237. 

diagnosis, 242. 

etiology, 203. 

expansive form, 227. 

galloping variety, 236. 

pathological anatomy, 207. 

physical symptoms, 217. 

prognosis, 245. 

remissions in, 242. 

symptomatology, 212. 

treatment, 246. 
Dementia prsecox, 152. 

catatonic form, 173. 

catatonic form, course, 184. 

catatonic form, physical symptoms, 

catatonic form, symptomatology, 174. 

diagnosis, 196. 

etiology, 152. 

hebephrenic form, 162. 

hebephrenic form, course, 169. 

paranoid forms, 188. 

paranoid forms, first group, 188. 

paranoid forms, second group, 191. 

pathological anatomy, 154. 

pathology, 153. 

physical symptoms, 160. 

prognosis, 200. 

symptomatology, 154. 

treatment, 200. 
Dementia, primary, 152. 
Desultoriness, 31. 
Dipsomania, 343. 
Disorientation, 15. 
Distractibility, 16, 44. 

of the will, 61. 



Double thought, 7. 
Drunkard's humor, 112. 

Echolalia, 180. 

Echopraxia, 180. 

Ecstasy, 52. 

Embolism, cerebral, insanity following, 

Emotional deterioration, 47. 
Emotional irritability, diminution of, 46. 

increase of, 48. 
Emotional tone, change of, 48. 
Emotions, disturbances of, 46. 

persistent morbid, 49. 
Encephalitis saturninia, 106. 

subcorticalis chronica progressiva, 
Epilepsy, idiopathic, 332. 

senilic, 331. 

tarda, 331. 
Epileptic dreamy states, 339. 
Epileptic insanity, 329, 348. 

diagnosis, 344. 

etiology, 330. 

pathology , v 331. 

physical symptoms, 337. 

prognosis, 346. 

symptomatology, 333. 
Epileptic somnambulism, 341. 
Epileptic stupor, 341. 
Epileptiform attacks, in delirium tre- 
mens, 122. 

in dementia paralytica, 218. 
Erotic paranoia, 321. 
Erythrophobia, 384. 
Etat crible, 274. 
Excitement, motor, 57. 
Exhaustion psychoses, 85. 

Fabrications, 21, 215. 

Fatigue, disturbance of the feeling of, 53. 

susceptibility to, 43. 
Fear, 46. 

Feeling of well being, 52. 
Fetichism, 67, 394. 
Fever delirium, 74. 

course, 75. 

etiology, 74. 

prognosis, 75. 

symptomatology, 74. 

treatment, 76. 
2 E 

Flight of ideas, 29, 287. 

delirious form, 30. 
Folie raisonnante, 291. 

General feelings, disturbances of, 53. 
General neuroses, 329. 
Gliosis, 249. 
Goal ideas, 25. 

incomplete development of, 29. 
Gynandry, 395. 

Hallucinations, 3, 5. 

auditory, 11. 

elementary, 4. 

of memory. (See fabrications.) 

visual, 10. 
Hasheesh delirium, 105. 
Head injury, insanity following, 252. 
Hebephrenia, 162. 
Hermaphroditism, psychic, 394. 
Humor, drunkard's, 52. 
Hunger, disturbances of the feeling of, 

Hydrocephalus ex vacuo, 273. 
Hyperprosexia, 17. 
Hypochondriasis, 98. 
Hypomania, 291. 
Hysterical dreamy states, 362. 
Hysterical insanity, 353. 

course, 365. 

diagnosis, 365. 

etiology, 353. 

pathology, 354. 

physical symptoms, 361. 

prognosis, 366. 

symptomatology, 356. 

treatment, 366. 
Hysterical somnambulism, 363. 

Ideas and concepts, disturbances of the 

formation of, 21. 
Ideas, persistence of, 26. 
Idiocy, 406. 

diagnosis, 411. 

etiology, 406. 

pathological anatomy, 407, 

physical symptoms, 410. 

prognosis, 412. 

symptomatology, 408. 

treatment, 412. 
Illusions, 3, 5. 



Imbecility, 397. 

active form, 400. 

course, 404. 

diagnosis, 404. 

stupid form, 398. 

treatment, 405. 
Impressibility, 19. 
Impulses, crossing of, 62. 

morbid, 66. 
Impulsive acts, 65. 
Impulsive insanity, 389. 

treatment, 391. 
Infection delirium, 76. 

course, 78. 

pathological anatomy, 76. 

prognosis, 78. 

symptomatology, 77. 

treatment, 78. 
Infection psychoses, 73. 
Insanity, alternating, 307. 

circular, 307. 

compulsive, 382. 

epileptic, 329. 

hysterical, 353. 

impulsive, 389. 

manic-depressive, 282. 

myxcedematous, 146. 
Insensibility, 14. 
Insight, absence of, 41. 
Insolation, insanity following, 252. 
Intoxication psychoses, 105. 

diagnosis, 114. 

prognosis, 113. 

treatment, 114. 
Intoxications, acute, 105. 

chronic, 107. 
Involution psychoses, 254. 

Judgment and reasoning, disturbances 
of, 33. 

Kleptomania, 67. 
Korssakow's disease, 82. 

course, 83. 

symptomatology, 82. 

treatment, 84. 

Lethargy, 14. 

Malaria, delirium of, 77. 
Mania, 293. 

Mania (continued) — 

delirious, 296. 

mitis, 291. 

periodical, 282. 

simple, 282. 

stuporous, 306. 
Maniacal states, 291. 
Maniacal stupor, 305. 
Manic-depressive insanity, 282. 

course, 307. 

depressive states, 299. 

diagnosis, 310. 

etiology, 283. 

lucid intervals of, 308. 

maniacal states, 291. 

mixed states, 305. 

pathology, 284. 

prognosis, 309. 

symptomatology, 284. 

treatment, 312. 
Mannerisms, 181. 
Masochism, 67. 
Megalomania, 228. 
Melancholia, 254. 

course, 262. 

diagnosis, 262. 

etiology, 255. 

pathological anatomy, 255. 

periodical, 282. 

physical symptoms, 261. 

prognosis, 263. 

simple, 282. 

symptomatology, 255. 

treatment, 264. 
Memory, disturbances of, 18. 

disturbances of the accuracy of, 20. 

disturbances of the temporal ar- 
rangement of, 20. 
Mental elaboration, disturbances of, 


Mental work, disturbances of the ca- 
pacity for, 43. 
Moral imbecility, 403. 
Morphin intoxication, acute, 135. 

chronic, 135. 
Morphinism, 134. 

abstinence symptoms, 137. 

course, 138. 

diagnosis, 138. 

etiology, 134. 

pathological anatomy, 134. 



Morphinism {continued) — 

prognosis, 139. 

symptomatology, 135. 

treatment, 139. 
Muscular tension, 178. 
Mutism, 177. 
Mysophobia, 384. 
Myxedematous insanity, 146. 

Nausea, disturbances of the feeling of, 

Negativism, 63, 176. 

Neurasthenia. {See acquired neurasthe- 
nia and congenital neurasthenia.) 

Nyktophobia, 383. 

Onomatomania, 383. 
Opium smoking, 106. 
Organic dementia, 249. 

diagnosis, 252. 

treatment, 253. 

Pain, disturbance of the feeling of, 55. 
Paralysis of thought, 24. 
Paralytic attacks in dementia para- 
lytica, 218. 
Paramnesia, 21. 
Paranoia, 316. 

alcoholic, 111. 

course, 324. 

diagnosis, 325. 

erotic, 321. 

etiology, 317. 

pathological anatomy, 317. 

periodical, 316. 

prognosis, 326. 

religious, 321. 

symptomatology, 317. 

treatment, 326. 
Paresis. {See dementia paralytica.) 

ascending, 222. 
Perception, disturbances of, 3. 

phantasms, 4. 
Periodical mania, 282. 
Periodical melancholia, 282. 
Persistent ideas, 25. 
Pleasure, morbid feelings of, 51. 
Post-epileptic insanity, 339. 
Post-febrile infection psychoses, 79. 

diagnosis, 81. 

prognosis, 81. 

Post-febrile infection psychoses {con- 
tinued) — 

symptomatology, 79. 

treatment, 82. 
Practice, 43. 

Pre-epileptic insanity, 339. 
Pre-senile delusional insanity, 267. 

course, 270. 

diagnosis, 271. 

etiology, 267. 

prognosis, 272. 

symptomatology, 267. 

treatment, 272. 
Pressure of activity, 58, 288. 
Pseudo-hallucinations, 7. 
Pseudo-paresis, alcoholic, 132. 
Psychic epilepsy, 340. 
Psychoses, infection, 73. 
Pyromania, 67, 389. 

Querulent insanity, 326. 

Rambling thought, 30. 
Keflex hallucinations, 8. 
Relaxation, 43. 
Religious paranoia, 321. 
Remissions, in catatonia, 184. 

in dementia paralytica, 242. 
Reperception, 6. 
Retardation, 59, 290. 

of thought, 24. 

with delusions and hallucinations, 
Retentiveness of memory, 19. 

Sadism, 67. 

Santonin delirium, 105. 

Self-consciousness, disturbances of, 44, 

Senile confusion, 277. 

Senile delirium, 278. 

Senile dementia, 273. 

course, 280. 

diagnosis, 280. 

etiology, 273. 

pathological anatomy, 273. 

physical symptoms, 279. 

symptomatology, 275. 

treatment, 280. 
Sexual feelings, disturbances of, 55. 
Sexual instincts. {See contrary sexual 
instincts. ) 



Smallpox delirium, 77. 

Sound associations, 289. 

Speech, disturbances of, in paresis, 220. 

scanning, 221. 
Spirit possession, delusions of, 194. 
Status epilepticus, 337. 
Stereotypy, 62. 

Stigmata, physical, in idiocy, 411. 
Stupor, 59. 

catatonic, 176. 

epileptic, 341. 

manic-depressive, 303. 
Stuporous mania, 306. 
Syphilis, hereditary, 249. 

in dementia paralytica, 204. 

Thought, acceleration of, 43. 

disturbances of the rapidity of, 42. 

retardation of, 42. 
Thyroigenous psychoses, 146. 

course, 147. 

etiology, 146. 

symptomatology, 146. 

treatment, 148. 

Train of thought, 23. 
Transitory periodical ill humor in epi- 
leptic insanity, 338. 
Traumatic neuroses, 371. 

diagnosis, 375. 

etiology, 371. 

physical symptoms, 373. 

prognosis, 376. 

symptomatology, 372. 

treatment, 376. 

Unconsciousness, 13. 

Volition and action, disturbances of, 

Volitional impulses, diminution of, 
disturbances in the release of, 57. 
increase of, 57. 

Will, diminished susceptibility of, 63. 
heightened susceptibility of, 60 
hypersuggestibility of, 61. 
weakness of, 60. 

Works on Medicine and Surgery 





A System of Medicine. By Many 
Writers. Edited by Thomas Clif- 
ford Allbutt, MA., M.D., LL.D., 
F.R.C.P., F.R.S., F.L.S., F.SA. Re- 
gius Professor of Physic in the Univer- 
sity of Cambridge, etc. In nine volumes. 

Vol. I. Prolegomena and Fevers. 

Vol. II. Infective Diseases and Toxicology. 

Vol. III. General Diseases of Obscure 
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